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PRIZE    ESSAY 


OHOLEEA    IKFA:t^TUM^ 

By  JAMES  JSTEWART,  M.  D., 
Author  of  "  A  Practical  Treatise  on  the  Diseases  of  Children." 


Si  quid  novisti  rectius  istis, 
Candidas  imperti ;  si  non,  his  utere  mecum. 

Hor.,  Epist.  vi.  67. 


Cholera  Infantum  is  usually  regarded  as  a  disease  pecu- 
liar to  the  United  States  ;  and  its  appearance  in  the  cities 
throughout  our  land  is  expected  with  as  much  certainty  as  is 
the  season  to  which  it  owes  its  existence.  With  this  certainty 
as  to  the  time  of  its  appearance,  is  to  be  added  the  uniformity 
it  observes  in  its  prevalence  at  a  distinct  period  of  life  ;  both 
showing  the  unchangeable  nature  and  uniform  operation  of 
the  agents  which  are  active  in  its  production.  No  summer 
passes  without  leaving  evidences  of  the  power  a  season  can 
exert  over  human  life,  and  how  remarkably  that  power  is 
active  in  the  development  of  a  peculiar  affection  at  a  distinct 
period  of  existence. 

Most  endemic  diseases  attack  indiscriminately  at  all  ages; 
this  one,  as  its  name  indicates,  is  confined  to  the  tenderest 
age,  while  there  is  no  disease  that  simulates  it  in  its  most 
marked  characteristics  at  any  other  age.  The  kindred  affec- 
tion that  has  of  late  scourged  so  many  countries,  is  uncer- 
tain as  to  the  time  of  its  invasion,  and  erratic  in  its  course  in 
different  countries,  yet  apparently  observes  some  law  of  pro- 
21 


286  Essay  on  Cholera  Infantum. 

gression  ;  while  the  cholera  of  infants  never  yet  has  failed  to 
commit  its  ravages  when  the  proper  atmospheric  condition 
for  its  development  exists,  and  is  as  steadily  fixed  to  its  local- 
ity as  any  of  the  natural  products  of  a  climate.  Such  is  the 
experience  of  American  physicians,  and  it  is  by  them  alone 
that  any  description  of  the  disease  has  been  given. 

It  has  been  stated  that  a  disease  exists  in  England  among 
infants,  similar  to  that  which  has  so  much  occupied  the  atten- 
tion of  practitioners  in  our  country.  If  this  be  so,  it  must  be 
vastly  less  in  extent  and  virulence  than  the  disease  as  it  pre- 
vails in  the  United  States ;  for  we  find  nothing  in  the  way  of 
description,  but  in  its  place,  surmises  that  an  infantile  affec- 
tion of  the  bowels  existing  there,  is  the  same  as  that  called 
cholera  infantum.  Had  there  been  the  same  certainty  of  the 
annual  return  of  the  disease  or  any  approximation  to  its  mor- 
tality, there  would  not  have  been  wanting  numerous  essays 
on  BO  interesting  a  subject  from  the  profession  in  Great  Bri- 
tain. It  is  also  said  that  Dr.  Cleghorn  described  among  the 
diseases  of  Minorca,  one  similar  to  that  which  prevails  so 
extensively  here  during  the  summer  among  infants  ;  if  so,  it 
would  appear  to  prove  that  the  like  disease  did  not  exist  in 
Great  Britain,  or  it  would  certainly  have  been  noticed  by  the 
distinguished  Dublin  Professor,  who  was  at  one  time  an  asso- 
ciate in  London  of  those  world-renowned  observers,  Fother- 
gill,  Cuming,  and  Kussell.* 

French  writers  say  that  there  is  nothing  analogous  to  this 
disease  in  France ;  and  when  considering  it  in  systematic 
works  on  children's  diseases,  give  a  description  of  it  derived 
from  American  authors.f 

In  the  absence,  therefore,  of  testimony  to  the  contrary, 
there  seems  to  be  some  foundation  for  the  opinion  that  it  is 
peculiar  to  the  United  States. 

*  See  Appendix,  A. 

I  "  Cholera  is  not  generally  noticed  in  our  climate ;  it  is  a  disease  peculiar 
to  infants  in  the  United  States;  and  as  I  have  not  observed  any  thing  analo- 
gous to  this  affection,  I  must  be  indebted  to  Dr.  Dewees  for  the  principal  de- 
tails of  the  symptoms." — Billard  on  Infanta.    American  edition,  p.  828. 


Essay  on  Cholera  Infantum.  287 

In  the  course  of  our  remarks  on  the  nature  of  the  disease, 
it  will  be  seen  that  at  a  particular  period  of  life  an  exaltation 
of  certain  functions  will  arise  in  the  course  of  the  natural  de- 
velopment of  the  body,  which  often  results  in  derangements 
of  the  alimentary  canal.  This  action  becoming  aggravated, 
will  bear  a  very  close  resemblance  to  the  disease  in  question, 
especially  in  its  first  stage,  yet  still  wanting  some  of  its  char- 
acteristic symptoms.  These  symptoms  appear  to  be  the 
result  of  the  combined  action  of  the  different  external  causes 
of  the  disease,  which  constitute  the  physical  conditions  of  a 
country  in  its  relations  to  organic  life.  The  presence  of  these 
agents  is  necessary  to  produce  the  disease  in  all  its  power : 
when  they  are  absent,  an  imperfect  development  of  it  occurs, 
as  is  doubtless  the  case  in  the  instances  referred  to  above. 

Etiology. 

That  a  clear  idea  of  the  causes  of  this  disease  may  be 
obtained,  with  a  view  to  investigate  its  pathology  and  the 
strictly  practical  application  of  remedial  measures,  it  is  pro- 
posed to  subject  all  the  circumstances  which  are  observed  to 
control  its  development  to  a  careful  examination.  There  is 
no  disease  which  appears  to  demand  so  close  an  investigation 
of  this  nature,  for  there  is  none  which  has  its  pathology  so  in- 
timately connected  with  the  action  of  the  agencies  which  are 
in  constant  exercise  in  its  production,  and  in  its  maintenance 
throughout  its  course.  The  combination  of  these  active 
agents, — constituting  what  is  known  as  climate,  the  more  spe- 
cial local  agents,  and  the  physiological  peculiarities  of  the 
period  of  life  at  which  the  disease  occurs,  it  will  be  seen  are 
all  connected  in  the  production  and  maintenance  of  the  same 
pathological  results,  so  formidable  in  their  action,  and  so  ob- 
stinate in  their  management.  These  circumstances  are  not  to 
be  regarded  as  mere  isolated  facts,  but  as  an  important  group, 
which  are  essential,  when  connected  with  the  phenomena  of 
the  disease  and  its  morbid  anatomy,  to  illustrate  the  morbid 
condition  of  the  system :  none  of  them  can  be  separated 


288  Essay  on  Cholera  Infantum. 

without  impairing  the  relation  they  bear  to  the  nature  of  the 
disease. 

Observation  1st. — Aim^ospheric  Heat. — ^The  most  com- 
mon attendant  on  the  development  of  the  disease,  is  a  high 
temperature. 

In  the  city  of  Kew  York,  during  a  period  of  eleven  years, 
out  of  twelve  hundred  and  forty-five  deaths  from  cholera 
infantum,  ten  hundred  and  sixty-one  occurred  during  the 
months  of  July,  August,  and  September,  the  three  hottest 
months, — and  but  six  during  the  three  coldest. 

The  next  highest  in  number  as  influenced  by  a  high  range 
of  temperature,  but  which  includes  all  ages,  is  dysentery. 

The  depression  of  temperature  exhibits  a  diflference  also 
in  its  effects,  but  nothing  in  comparison  with  that  caused  by 
a  high  range.  Thus  croup  presents  the  greatest  difference 
from  this  cause,  and  of  twelve  hundred  and  thirteen  deaths 
presents  in  no  month  less  than  sixty-six, — in  the  three  summer 
months,  two  hundred  and  twenty,  and  in  the  three  winter 
months  no  greater  increase  than  three  hundred  and  ninety- 
eight.* 

In  the  entire  number  reported,  none  shows  so  great  a  dif- 
ference from  temperature  as  the  disease  under  consideration. 

So  uniformly  has  this  disease  existed  in  the  city  of  New 
York  during  the  hot  months  alone,  that  there  is  no  year  of 
which  there  is  any  record  of  diseases,  that  deaths  from  it  are 
not  reported  as  steadily  increasing  in  number  with  the  in- 
crease of  temperature.  For  fifty  years  past,  from  180i  to 
1854,  a  large  number  of  deaths  has  been  officially  reported 
from  cholera  infantum  during  the  summer  season,  with  the 
exception  of  one  year,  when  there  appears  in  the  official  reg- 
ister but  one  death  from  this  cause.  This  occurred  in  the 
year  1816.  On  looking  over  the  periodicals  and  newspa- 
pers of  that  year,  it  appears  that  the  summer  of  1816  was 
singularly  cold,  the  thermometer  up  to  the  25th  of  July  being 
from  15°  to  20°  below  the  summer  temperature,  and  after 
that  period  the  mean  temperature  was  but  61° — that,  of  the 

*  See  Appendix,  B. 


Essay  on  Cholera  Infantum.  289 

three  months  68°  ;  a  sudden  elevation  for  a  day  or  two  raising 
the  mean,  while  the  actual  continuation  of  the  cold  for  the 
season  was  without  a  parallel.*  Cholera  infantum  appears 
scarcely  to  exist  when  the  mean  temperature  is  about  60°. 

Although  the  mean  is  usually  given  as  an  evidence  of  the 
effect  of  temperature  in  producing  disease,  yet  it  is  obvious 
that  it  is  more  correctly  attributable  to  the  diurnal  range. 
The  mean  temperature  of  a  week,  can  give  but  little  informa- 
tion as  to  the  effects  of  heat  when  the  thermometer  has  been 
at  or  above  90°.  The  high  temperature  of  95°  will  produce 
serious  and  often  suddenly  fatal  disease,  while  the  mean  of 
75°  could  furnish  no  explanation. 

The  invasion  of  cholera  infantum  occurs  immediately 
after  a  period  of  excessive  heat,  and  is  one  of  its  most  marked 
effects. 

Obsekvation  2d. — Excessive  humidity  of  the  air. — ^The 
condition  of  the  atmosphere  with  respect  to  its  humidity  is 
one  of  the  elements  which  imparts  to  a  country  its  pe- 
culiarity as  regards  disease.  There  does  not  appear  to  be 
much  difference  in  the  annual  mean  in  various  parts  of  the 
northern  section  of  our  country,  and  the  diseases  incident  to 
it  present  much  the  same  characters.  The  humidity,  however, 
is  much  modified,  and  often  immoderately  developed  under 
the  occasional  changes  which  occur  in  the  atmosphere  ;  but 
more  especially  is  it  increased  in  circumscribed  localities  and 
in  crowded  dwellings. 

The  temperature  at  which  moisture  is  deposited,  is  usually 
taken  to  ascertain  the  amount  of  moisture  in  the  air.  When 
the  temperature  of  deposit,  or  as  it  is  termed  dew-point,  is 
high,  and  especially  when  it  continues  high  for  some  time  in 
hot  weather,  the  system  feels  its  depressing  influence.  All 
persons  suffer  from  a  sensation  of  lassitude  and  sweltering 
oppression  at  such  times ;  but  no  class  equal  to  young  chil- 
dren.    During  the   sultry  nights  of  summer,  in  the  over- 

*  See  Appendix,  C. 


290  Essay  on  Cholera  Infamium. 

crowded  habitations  of  tlie  poor,  they  show  the  effects  in  their 
excessive  pallor,  languor,  and  exhaustion. 

In  our  investigations  on  the  subject  of  atmospheric  hu- 
midity, and  its  relation  to  the  disease  under  consideration,  we 
have  examined  various  localities,  and  found  as  was  expected, 
that  a  great  difference  existed.  As  to  the  city  of  J^ew  York, 
we  have  carefully  compared  the  observations  made  for  the 
Smithsonian  Institution  by  Prof.  O.  W.  Morris,  of  the  Deaf 
and  Dumb  Asylum,  with  those  which  we  have  taken ;  and 
have  come  to  the  conclusion  that  ordinary  climatic  humidity 
has  but  limited  influence  on  the  development  of  cholera  in- 
fantum. The  same  amount  of  moisture  often  exists  in  coun- 
try places  as  is  found  in  the  city,  and  where  the  disease  was 
never  known  to  originate.  We  therefore  directed  our  atten- 
tion to  the  occasional  state  of  the  dew-point  as  it  occurred 
where  the  disease  was  most  prevalent,  and  discovered  a  great 
difference  within-doors,  between  it  and  the  general  dew-point 
of  the  external  air,  continuing  often  for  a  long  time. 

The  first  observation  made  was  that  the  moisture  was 
always  greater  nearer  the  surface  of  the  earth ;  the  difference 
we  have  ascertained  to  be  at  times  4°.  Cellars  and  baselnents 
must  therefore  always  be  in  a  state  of  excessive  humidity, 
as  is  known  to  most  persons,  requiring  no  philosophical  in- 
strument for  its  detection. 

The  second  is  that  in  very  hot  weather  in  excessively 
crowed  houses  at  night,  when  all  are  within,  the  dew-point  is 
very  nearly  at  the  temperature  of  the  air,  consequently  the 
air  is  saturated  with  moisture.  With  a  temperature  of  90°  to 
95°  and  a  dew-point  in  a  crowded  room  almost  equal  to  the 
temperature,  a  feeling  of  suffocation  is  experienced,  which  is 
easily  accounted  for  when  it  is  known  that  the  dew-point  of 
the  breath  as  it  is  expelled  from  the  lungs  is  94°,  and  that 
the  mean  dew-point  of  the  atmosphere  is  38°  ;  and  also,  that 
in  the  hottest  weather  it  rarely  exceeds  70°.  When  the  air 
is  loaded  with  moisture  and  deposited  easily  at  a  temperature 
approaching  to  that  of  the  living  body,  inspiration  is  difficult 
and  unsatisfactory,  while  the  system  suffers  great  depression. 


Essay  on  Cholera  Infantum.  291 

The  effects  will  be  again  referred  to,  when  the  pathology  of 
the  disease  is  considered. 

It  is  in  such  heated  and  moist  places  that  we  have  found 
the  greatest  number  of  instances  of  cholera  infantum. 

Obsekvatiout  3d. — Malaria. — This  cause  has  been  regard- 
ed as  the  principal  agent  in  the  production  of  cholera  infant- 
um ;  meaning  by  it  an  atmosphere  infected  by  marsh  efflu- 
vium. It  is  ascribed  to  this  by  some  writers,  and  also  by  the 
Committee  "  On  the  Epidemics  of  Tennessee  and  Kentucky," 
in  their  report  to  the  American  Medical  Association  in  1853. 
This  report,  and  that  made  in  1854,  are  the  most  recent  pub- 
lished remarks  upon  the  subject.  It  would  seem,  however, 
more  in  accordance  with  well-known  facts  to  consider  the 
malaria  of  crowded  places,  as  the  kind  of  malaria  which  pro- 
duces the  disease.  The  report  first  referred  to  appears  to 
admit  this  to  a  certain  extent,  as  it  speaks  of  the  air  of  apart- 
ments that  have  been  carefully  closed  at  night  to  keep  the 
external  malaria  excluded,  as  being  the  places  where  the 
medical  practitioner  is  frequently  called  to  see  the  disease. 

Cholera  infantum  in  some  mitigated  form  may  arise  in 
the  country,  since  it  will  appear  in  the  course  of  this  essay 
that  many  of  its  causes  will  exist  in  different  places  under  the 
influence  of  a  high  range  of  temperature,  and  different  grades 
will  probably  be  found  in  places  remote  from  each  other. 
There  is,  however,  so  great  a  modification  and  so  peculiar  a 
type  out  of  the  cities  as  to  make  it  more  of  a  severe  diarrhoea, 
complicated  with  fever,  receiving  its  characteristic  type  from 
the  condition  of  the  air  producing  it,  but  differing  much  from 
the  virulent  disease  as  it  occurs  in  cities. 

Inasmuch  as  the  usual  cause  of  endemic  fevers  in  the 
country  has  been  regarded  as  the  cause  of  this  disease,  a  ref- 
erence to  the  nature  and  source  of  the  two  kinds  of  malaria, 
with  the  mode  in  which  their  effects  are  manifested,  will  be 
necessary  to  exhibit  them  in  their  proper  character,  and  by 
comparing  them,  endeavor  to  ascertain  whether  there  exists 
any  dissimilarity.    This  can  be  very  briefly  done  by  avoid- 


292  Essay  an  Cholera  Infantum. 

ing  tlie  consideration  of  every  thing  that  can  complicate  the 
inquiry,  especially  of  all  subjects  connected  with  the  discus- 
sion of  the  pathology  of  miasmatic  diseases,  and  by  keeping 
closely  to  the  inquiry  into  their  origin  and  their  effects. 

The  malaria  of  the  country  is  produced  by  emanations 
from  marshy  places,  and  by  a  dessication  of  the  surface  of  the 
ground  both  by  solar  heat  and  by  the  passage  of  currents  of  air 
over  it,  carrying  into  the  body  of  the  atmosphere  the  minute 
gaseous  results  of  vegetable  decomposition.  That  which  is 
exclusively  of  the  city,  it  is  obvious,  cannot  be  produced  in 
the  same  manner,  the  surface  of  the  streets  not  admitting  of 
such  constant  evaporation  by  the  solar  rays  or  by  the  passage 
of  currents  of  air  ;  indeed  the  absence  of  the  sun's  rays,  and 
that  also  of  the  movements  of  the  air,  are  always  considered 
as  the  principal  causes  of  the  diseases  that  are  peculiar  to 
cities.  If  air  from  malarious  districts  is  borne  into  the  cities, 
it  must  be  very  considerably  modijfied  by  the  mixture  with 
that  which  is  always  found  in  cities  and  other  crowded  places. 

That  of  the  country  is  derived  principally  from  a  vegeta- 
ble source,  together  with  the  saturation  of  the  soil  from  time 
to  time  with  rain,  and  its  evaporation  and  diffusion.  The  an- 
imal element  forms  the  principal  part  of  that  of  the  city ; 
arising  from  the  changes  which  the  air  undergoes  from  the 
depuration  from  the  bodies  of  living  animals  where  many  are 
crowded  together,  and  the  decomposition  of  dead  animal  mat- 
ter. Slaughter-houses,  soap  manufactories,  the  refuse  of  sta- 
bles, sinks,  cess-pools  and  other  receptacles  of  a  similar  kind, 
are  among  the  common  sources  of  the  bad  air  of  cities,  and 
which  impart  to  the  mass  of  the  air  qualities  not  elsewhere  to 
be  found. 

The  sensible  effects  of  the  two  are  different.  In  general 
there  is  no  odor  in  that  of  the  country,  while  in  the  malaria  of 
cities  it  is  decidedly  manifest. 

It  has  been  remarked  (History  and  Cure  of  Fevers,  by  R. 
Jackson,  part  i.,  chap,  iii.)  that  the  miasma  of  crowded  places 
differs  from  that  of  a  paludal  nature,  by  being  less  volatile, 
and  confined  to  a  more  limited  space ;  and  that  it  is  more  con- 


Essay  on  Cholera  Infantum.  293 

centrated  in  its  effects,  producing  an  exhausting  and  depress- 
ing action  in  a  more  decided  manner. 

The  morbid  effects  are  different. 

In  all  parts  of  the  world,  the  tendency  to  diseases  in  the 
country  is  to  an  intermittent  or  remittent  type,  such  as  fevers, 
the  common  head-ache,  and  neuralgic  affections.  Those  of 
the  city  assume  more  frequently  a  continued  form,  even  where 
there  is  no  specific  contagion  manifest. 

The  action  of  malaria  from  the  soil  is  remarkable  also  for 
the  production  of  epizootic  diseases.  From  the  time  of  the 
Latin  poets  and  historians  to  the  most  recent  medical  reports 
and  essays  of  the  present  day,  in  every  country,  we  hear  of 
extensive  diseases  that  have  prevailed  at  different  times 
among  quadrupeds,  from  paludal  effluvia.  Such  diseases  and 
such  mortality  are  very  rare  in  cities.  We  have  heard  of 
sickness  among  horses  in  the  vicinity  of  a  city  during  a  pes- 
tilence ;  but  a  decided  epizootic  is  of  rare  occurrence  and  of 
very  limited  extent  within  its  bounds ;  and  where  an  epi- 
demic prevails  in  such  places,  the  simultaneous  sickness 
among  quadrupeds  is  recorded  as  a  remarkable  event.* 

In  the  country,  malaria  would  seem  to  require  a  tempo- 
rary or  transient  cold  state  of  the  air,  or  of  the  body,  to  pro- 
duce its  effects  on  the  system.  So  universally  remarked  is 
this,  that  the  exposure  to  the  cool  night  air  is  considered  as 
sure  to  produce  a  malarious  fever ;  and  it  has  been  referred 
to  the  cooling  of  the  body  by  terrestrial  radiation,  when  sol- 
diers have  been  taken  sick  who  slept  on  the  ground  without 
tents  or  other  covering,  while  those  who  have  had  bushes, 
trees,  or  tents  over  them  have  escaped.  It  cannot  be  the  same 
malaria  that  produces  cholera  infantum  as  witnessed  in  cities, 
inasmuch  as  it  always  attacks  the  greatest  number  while  the 
heat  is  greatest,  and  no  danger  is  apprehended  from  its  tem- 
porary mitigation.f 

In  the  country,  disease  from  malaria  mostly  attacks  adults ; 

*  See  Appendix,  D.  f  See  Appendix,  E. 


294  Essay  on  Cholera  Infantwm. 

infants  born  in  such  places  are  in  general  exempt.  The  re- 
verse is  the  case  in  cities  ;  children  are  the  most  subject  to  its 
malarious  influences,  and  the  natives  are  the  first  to  experi- 
ence their  effects  when  the  season  arrives  to  set  them  in  ac- 
tion. The  great  mortality  from  cholera  infantum  shows  that 
there  is  but  little  exemption  from  its  effects  among  them. 

If  this  disease  is  caused  by  the  same  influences  that  pro- 
duce malarious  fevers,  it  would  prevail  at  the  time  such  fevers 
exist.  On  the  contrary,  the  greatest  number  of  cases  occur 
in  July  and  August,  and  when  they  begin  to  lessen  in  num- 
ber, the  paludal  fevers  increase.  "We  should  also  expect  to 
find  it  prevail  more  during  the  season  when  cases  of  autumnal 
fever  occur  in  the  greatest  number.  This,  however,  is  not  the 
case,  where  we  have  had  opportunities  of  obtaining  the  most 
reliable  information.  Whatever  amount  of  sickness  exists  in 
the  country  surrounding  the  city  of  ISTew  York,  cases  of  chol- 
era infantum  observe  a  remarkable  uniformity  as  to  numbers, 
evidently  under  influences  different  from  those  producing  the 
febrile  affection.  In  the  year  1828,  malarious  fever  prevailed 
very  extensively  and  with  great  severity  in  the  country 
around  that  city,  proving  fatal  in  a  great  number  of  instances. 
Many  of  the  villages  were  nearly  destitute  of  inhabitants, 
farms  were  offered  for  sale  or  to  lease  by  their  terror-stricken 
owners,  and  persons  unaffected  by  the  disease  were  scarcely 
in  sufficient  numbers  to  attend  upon  the  sick.  Hundreds  fled 
from  all  parts,  even  from  the  immediate  vicinity  of  the  city, 
and  took  refuge  within  its  precincts.  Yarious  parts  of  New 
Jersey,  Staten  Island,  Westchester  county,  and  the  regions 
particularly  near  the  city,  were  the  principal  places  affected 
by  the  disease.  It  also  prevailed  with  great  severity  on  Long 
Island,  where  it  was  attributed  to  malaria  from  decaying  vege- 
table substances  exposed  to  great  heat.  Several  communica- 
tions appeared  in  the  daily  newspapers  on  the  subject,  and 
they  speak  of  noxious  vapors  of  which  a  single  inspiration  was 
injurious.* 

*  S«e  Appendix,  F. 


Essay  on  Cholera  Infantum.  295 

During  that  year,  the  mortality  from  cholera  infantum  in 
the  city  of  New  York  was  one  hundred  and  sixty-one,  or  one 
in  thirty -one  of  the  whole  number  of  deaths  ;  not  so  great  as 
in  the  two  previous  years,  when  they  amounted  respectively 
to  two  hund  red  and  twenty-two  and  two  hundred  and  thirty- 
eight,  or  one  in  twenty-two  of  the  deaths.  This  was  also  the 
case  in  other  years  ;  a  reference  to  which  is  made  in  the  Ap- 
pendix.* 

The  disease  we  are  considering  appears  to  differ  essentially 
in  miasmatic  places  from  that  which  occurs  in  cities.  The 
number  of  cases  of  cholera  infantum  "  under  15  years,"  of 
which  the  statistics  are  given  in  the  report  above  referred  to, 
as  occurring  in  1852,  in  the  States  of  Kentucky  and  Tennessee, 
is  fifty-two.  The  average  attendance  of  fourteen  of  them  was 
four  days,  and  of  seven,  nine  days.  The  period  of  attendance 
required  by  the  remainder  is  not  given,  while  the  mortality 
of  the  whole  number  was  four.  It  would  seem  therefore  to 
differ  from  the  disease  known  by  the  same  name  in  cities.f 

In  the  report  on  the  diseases  of  the  same  district  for  the 
year  1853,  one  hundred  and  thirty-five  is  the  number  given 
for  the  entire  State  of  Kentucky.  The  necessity  there  stated 
for  using  quinine  in  its  treatment  indicates  also  a  very  essen- 
tial modification  of  the  disease  in  the  western  part  of  the  Uni- 
ted States.  The  repor  t  also  states  that  on  a  comparison  with 
other  diseases  that  prevail  there,  cholera  infantum  has  a  near- 
er relationship  to  dysentery  and  typhoid  fever  than  to  bilious 
fever  ;  from  which  there  would  seem  to  be  an  admission  that 
there  is  some  other  exciting  cause  than  that  which  produces 
paludal  fever. 

Cholera  infantum  appears  in  diminished  numbers  in  pro- 
portion to  the  distance  from  crowded  places,  and  is  most  suc- 
cessfully trea  ted  when  the  patient  is  removed  out  of  the  lim- 
its of  the  city  even  to  a  short  distance ;  but  if  the  disease 
came  from  one  and  the  same  cause,  and  that  cause  marsh 
miasm,  no  mitigation  would  occur  by  moving  into  the  air 

*  See  Appendix,  G.  f  See  Appendix,  H. 


296  Essay  on  Cholera  Infantum. 

which,  from  its  greater  proximity  to  the  source  of  the  poison, 
would  be  more  active  in  producing  its  deleterious  effects. 

From  the  facts  now  stated,  so  far  as  cholera  infantum  is  de- 
pendent on  external  causes,  it  is  evident  that  in  addition  to 
high  range  of  temperature  and  inordinate  atmospheric  humid- 
ity combined,  it  has  for  its  cause  the  peculiar  malaria  of 
crowded  places. 

Observation  4th. — Period  of  Life.  —  Cholera  infantum 
prevails  more  before  the  first  year  than  during  any  other  pe- 
riod. Although  there  are  no  published  statistics  that  show 
the  mortality  at  the  early  months,  yet  it  is  well  known  to  all 
practical  men  that  the  disease  prevails  less  during  the  first 
six  months  and  more  from  that  time  to  half  of  the  first  year. 
From  the  first  to  the  end  of  the  second  year  it  exists  with 
varied  intensity  in  different  individuals,  and  after  the  second 
year  the  number  is  small. 

In  the  city  of  Philadelphia,  during  a  period  of  twenty 
years,  prior  to  1827,  there  were  three  thousand  eight  hundred 
and  twelve  deaths  reported  from  disease  designated  under  the 
general  title  of  cholera,  among  persons  of  all  ages — cholera 
morbus  or  cholera  infantum.  Of  this  number  three  thousand 
three  hundred  and  eight  were  under  the  age  of  two  years  ;  all 
of  which  were  doubtless  the  cholera  of  infants^  as  that  term 
is  used  to  designate  a  specific  disease.* 

In  the  city  of  New  York  of  fifteen  hundred  and  twenty- 
five  deaths  from  this  cause  in  1854,  thirteen  hundred  and 
sixty -four  were  under  the  age  of  two  years,  and  of  three  thou- 
sand one  hundred  and  sixty  deaths  which  occurred  in  three 
years,  two  thousand  seven  hundred  and  forty-seven  were  un- 
der that  age. 

The  time,  therefore,  at  which  the  disease  is  at  its  height  is 
that  of  the  period  of  second  infancy,  when  important  physiolo- 
gical changes  occur,  manifested  by  the  appearance  of  the  teeth, 
the  development  and  activity  of  the  salivary  glands,  together 

*  See  Appendix,  I. 


Essay  on  Cholera  Infantum.  297 

with  alterations  in  all  the  organs  of  digestion  ;  a  state  of  sys- 
tem which,  it  will  be  seen,  when  considering  the  pathology  of 
the  disease,  is  inseparably  connected  with  its  development. 

Observation  6th. — Inappropriate  Food. — This  is  an  occa- 
sional exciting  cause,  acting  with  those  already  mentioned. 
"Where  a  child  is  artificially  fed,  there  are  often  indigestible 
substances  of  a  farinaceous  or  starchy  nature  given,  that 
greatly  disorder  the  digestive  organs,  from  the  impossibility 
of  assimilating  them  ;  these  organs  beiug  unfitted  for  the  re- 
ception of  vegetable  aliments.  There  is  another  formof  food, 
which  does  not  appear  to  have  attracted  the  notice  of  writers 
on  cholera  infantum,  but  which  is  of  importance  when  consid^ 
ered  in  connection  with  the  causes  already  mentioned.  It 
is  the  deterioration  of  the  mother's  milk  from  the  debilitating 
effects  of  the  atmospheric  influences  already  considered.  The 
mother  suffers  as  well  as  the  child,  and  it  appears  quickly  in 
the  secretion  of  the  milk,  manifested  principally  in  its  lessened 
quantity,  while  the  process  of  nursing  is  one  of  fatigue  and 
exhaustion.  Even  if  it  is  difficult  to  prove  any  alteration  in 
the  chemical  qualities  of  the  milk,  yet  the  fact  is  well  estab- 
lished that  the  milk  will  undergo  changes  at  times  of  such  a 
nature  as  to  impart  injury  to  the  child.  We  have  proved  this 
by  withdrawing  the  child  from  the  breast,  although  in  gene- 
ral opposed  to  weaning  children  that  are  sick. 


General    Phenomena. 

At  the  present  stage  of  the  investigation  we  shall  state  the 
symptoms  in  a  general  way,  and  those  only  which  impart  a 
character  to  the  disease,  and  from  which  it  derives  its  distinctive 
name,  and  not  those  which  are  the  result  of  its  varied  forms  of 
manifestation  or  of  its  complications  ;  the  object  being  to  con- 
nect the  signs  of  derangement  which  distinguish  this  disease 
from  every  other,  with  the  causes  which  produce  them.  The 
statement  of  the  phenomena  in  detail  will  be  reserved  for  a 


298  Essay  on  Cholera  Infantum. 

section  on  the  semiology,  immediately  preceding  that  devot- 
ed to  the  treatment. 

The  disease  is  characterized  by  inordinate  evacuation  from 
the  bowels,  generally  accompanied  by  vomiting.  Whatever 
be  the  different  modes  of  its  invasion,  whether  with  or  with- 
out febrile  action  or  the  existence  of  nausea,  diarrhoea  is  usu- 
ally the  first  symptom.  The  simultaneous  existence  of  vom- 
iting and  purging  at  the  beginning  of  the  disease  indicates 
its  severity ;  and  under  such  a  mode  of  attack,  it  will  often 
terminate  fatally  in  a  few  days.  In  the  greatest  number  of 
instances,  the  diarrhoea  alone  is  its  earliest  manifestation,  at 
first  consisting  of  the  ordinary  fsecal  matters,  changing  soon, 
however,  to  a  serous  fluid  of  different  hues.  At  intervals  the 
discharge  consists  of  the  mucous  secretion  of  the  intestines, 
mixed  with  undigested  food.  The  odor  differs  from  ordinary 
faeces  ;  sometimes,  when  it  contains  the  ingesta,  it  is  indescri- 
bably offensive.  At  other  times  it  is  in  a  state  of  fermenta- 
tion which  imj)arts  an  acid  odor,  not  unlike  that  of  tlie  chyle 
before  it  has  reached  that  part  of  the  primge  vise  where  the 
biliary  duct  opens  into  the  intestines,  it  being  diluted 
only  with  the  follicular  secretion.  "When  the  disease  is  fully 
established,  the  absence  of  bile  is  one  of  its  distinctive  marks, 
while  the  discharges  indicate  ulceration.  Yomiting,  or  attempts 
at  vomiting,  is  another  prominent  symptom,  and  is  one  of  the 
most  uncontrollable  and  obstinate  of  all  the  phenomena.  The 
discharges  by  this  act  never  consist  of  any  thing  more  than 
the  food  or  drinks  that  have  been  given.  All  these  symptoms 
are  accompanied  by  inordinate  thirst. 

Next  appear  a  dry  and  flabby  state  of  the  skin,  with  in- 
tense heat  on  that  covering  the  abdomen.  Kapid  emaciation 
follows,  and  the  body  becomes  attenuated  to  a  most  frightful 
extent.  As  the  disease  advances  toward  a  fatal  termination,  the 
natural  stools  are  retained,  and  the  mucus  becomes  gelatinous, 
and  often  pink-colored.  The  disease  usually  lasts  a  month  or 
six  weeks. 

Lastly,  evidences  of  cerebral  disturbances  show  them- 
selves, with  occasional  convulsions.    These  and  other  compli- 


Essay  on  Cholera  Infantum.  299 

cations,  being  additions  to  the  essential  symptoms  of  the  dis- 
ease, are  not  here  particularly  noted,  although  constituting  a 
necessary  part  of  the  ultimate  development. 

MoKBiD  Anatomy. 

In  the  different  parts  of  the  intestinal  tube  there  are  found 
numerous  granules  having  at  their  external  surface  a  minute 
pore,  from  which  the  mucus  secreted  by  the  gland  is  exuded. 
They  are  known  as  the  mucous  glands  or  granules,  and  also  as 
the  muciparous  follicles.  Although  they  are  very  numerous 
in  the  upper  part  of  the  intestines,  yet  they  exist  detached 
from  each  other ;  while  fi'om  the  jejunum  downwards  they 
appear  in  groups.  But  one  function  is  discharged  by  them 
all,  that  of  furnishing  mucus  to  the  surface  of  the  intestines, 
although  they  are  distinguished  by  different  names  in  different 
parts  of  the  intestines.  They  will  be  considered  in  this  Essay 
with  reference  only  to  the  functions  they  perform,  and  de- 
nominated mucous  follicles. 

These  follicles  rarely  make  their  appearance  until  about 
the  time  of  teething,  when  a  general  development  of  all  the 
parts  connected  with  the  asimilating  process  takes  place. 
When  the  teeth  appear,  the  mucous  follicles  are  brought  into 
action,  and  are  apparently  connected  with  the  necessity  of  a 
change  of  food  for  the  child. 

In  cholera  infantum  the  most  remarkable  anatomical 
change  is  found  in  the  excessive  development,  the  functional 
activity,  inflammation,  and  occasional  ulceration,  of  these  fol- 
licles. 

Instead  of  pursuing  an  elaborate  detail  of  the  appearances 
presented  on  postmortem  examination  in  every  organ  and 
cavity  of  the  body,  many  of  which  are  secondary  and  the 
effects  of  complications,  we  will  refer  to  two  lithographic 
representations  of  the  actual  anatomical  changes  in  parts 
which  are  primarily  affected,  and  which  continue  to  be  the 
principal  parts  diseased,  whatever  modifications  the  disease 
may  assume ;  the  symptoms  of  the  local  derangement  which 


300  Essay  on  Cholera  Infantum. 

characterize  the  affection  always  being  aggravated  the  nearer 
the  approach  to  a  fatal  termination.  As  the  fairest  method 
also  of  ascertaining  the  morbid  changes,  we  propose  also,  to 
exhibit  an  analysis  of  all  the  postmortem  examinations  that 
have  been  recorded,  so  far  as  we  have  been  enabled  to  find 
them  in  the  different  medical  periodicals. 

Anatomical  Illustrations. — No  1.  The  colon  of  a  child, 
aged  6  months,  that  died  of  cholera  infantum.  The  mucous 
follicles  were  all  enlarged,  but  scarcely  any  of  them  were 
ulcerated — the  whole  mucous  surface  appeared  to  be  covered 
with  white  elevated  spots. 

No  2.  The  colon  of  a  child,  aged  1  year  and  8  months,  that 
died  of  cholera  infantum.  A  large  number  of  the  glands 
were  not  only  enlarged,  but  ulcerated  ;  indicated  in  the  ac- 
companying representation  by  the  central  dark  spot. 

Anatomical  Analysis. — On  examining  most  of  the  med- 
ical periodicals  which  have  been  published  within  the  past 
fifty  years,  we  have  found  recorded  the  postmortem  ex- 
amination of  thirty  cases  of  cholera  infantum.*  Of  this 
number  there  were  twenty-eight  reported  as  presenting 
the  liver  diseased,  either  by  being  congested,  enlarged, 
or  altered  either  in  color  or  texture.  Its  color  was  in 
many  instances  lighter  than  usual,  and  in  others  "  variega 
ted."  It  was  in  most  instances  firmer  than  is  the  case  in 
health.  Dr.  Horner  observes  that  the  liver  is  generally  en- 
larged and  of  a  more  firm  and  solid  texture  than  is  the  case 
in  the  natural,  healthy  condition.  Only  in  two  cases,  the 
liver  was  reported  healthy,  or,  as  it  is  termed  in  one  instance, 
"  appeared  healthy." 

The  next  fact  to  be  noticed  is,  that  in  the  whole  number, 
the  mucous  membrane  of  the  intestines  was  found  diseased, 
inflamed  with  mucous  exudation,  congested,  or  ulcerated. 
These  statements  were  made  before  Dr.  Horuer  published  the 

*  By  Drs.  Jackson,  N,  E.  Jour.  Med.,  v.  1 ;  Horner,  Am,  J,  Med.  Sci.  v.  20; 
Stuart,  Coxe's  Med.  Mis.  v.  3 ;  Baxter,  K  Y.  Med.  and  Phys.  Jour.  vi.  N.  S, ; 
Lindeley,  Am.  Jour.  Med.  Sci.  v.  24 ;  Hallowell,  Am.  Jour.  Med.  Sci.  v.  40. 


No.  1, 


No.  2. 


Essay  on  Cholera  Infantum.  301 

results  of  his  examinations.  He  observed  the  same  condition 
of  tlie  mucous  membrane  ;  but  on  removing  tlie  mucus  and 
blood  by  a  little  maceration,  he  was  enabled  to  note  the  true 
organic  changes  that  had  occurred,  by  discovering  the  delicate 
prominences  of  thousands  of  inordinately  developed  mucous 
follicles — a  large  number  of  them  in  a  state  of  ulceration.  In 
the  examination  of  two  cases  by  Dr.  Baxter  and  twelve  by 
Dr.  Hallowell,  the  same  condition  was  found,  and  which  is 
also  represented  in  the  lithographs  accompanying  this 
Essay. 

The  disease,  therefore,  exists  mainly  in  the  mucous  follicles 
and  in  the  liver.  The  effusions  and  congestions  in  the  brain  and 
other  organs  are  clearly  complications  of  the  original  disease; 
and  although  exhibiting  serious  affections  of  those  parts,  yet 
these  organs  do  not,  so  far  as  we  have  been  able  to  ascertain, 
present  any  decided  alteration  in  the  structure  itself,  as 
is  found  in  the  liver  and  mucous  surface  of  the  intestines. 


Pathology. 

The  pathology  of  a  disease  should  be  studied  closely  in  con- 
nection with  the  causes  which  produce  the  morbid  changes  ex- 
hibited on  postmortem  examinations.  It  is  evident  that  an  an- 
atomical investigation  can  give  us  only  the  morbid  results  of 
diseased  action,  and  is  therefore  to  be  regarded  as  but  one 
extremity  of  the  continuation  of  a  morbid  condition  of  parts  ; 
the  other  exists  inscrutable  to  us,  except  in  the  symptoms 
which  characterize  it,  and  in  the  immediate  results  of  the 
causes  in  operation  to  effect  the  changes  which  produce  these 
symptoms.  While  the  anatomical  alterations  show  us  the 
terminations,  we  must  seek  for  something  else  anterior  to  them 
for  instruction  as  to  the  actual  condition  of  the  living  parts 
at  the  commencement,  and  thus  endeavor  to  ascertain 
what  it  is  that  leads  to  these  changes.  Often  in  the  examina- 
tion of  the  philosophy  of  disease,  we  are  obliged  to  be  con- 
tented with  learning  from  the  symptoms  during  life,  and  the 
anatomical  condition  after  death,  on  wiiat  to  found  its  pathol- 
22 


302  EssoRi  on  Cholera  Infantum. 

ogj.  If  it  be  possible  to  add  to  them  tbe  known  causes,  and 
if  these  are  not  only  clearly  established,  but  are  found  to  be 
peculiar  in  their  immediate  effects,  we  obtain  a  starting  point 
of  great  importance,  which  if  carefully  studied  and  the  course 
indicated  by  them  be  as  carefully  pursued,  will  add  much  to 
our  ability  to  interpret  the  revelations  of  the  scalpel. 

As  cholera  infantum  can  be  referred  to  well-ascertained 
canses,  and  as  these  agents  are  in  action  to  maintain  the  dis- 
ease, when  established,  by  their  constant  and  positive  influ- 
ences, there  can  scarcely  be  found  a  disease  that  can  so  well 
elucidate  the  imj)ortance  of  endeavoring  to  establish  the 
connection  between  the  early  morbid  action  and  the  ultimate 
morbid  results. 

It  is  for  this  reason  that  the  causes  already  exhibited  will 
be  taken  up  in  their  order,  their  philosophy  examined,  and 
the  morbid  conditions  produced  by  them  studied  in  connec- 
tion with  the  alterations  revealed  after  death. 

1st.  Heat. — The  effects  of  atmospheric  heat  on  the  sys- 
tem are  direct  and  indirect.  By  the  direct  effects  are  to  be 
understood  those  sudden  disorders  which  are  the  results 
of  an  accelerated  action  of  the  circulatory  organs,  or  the 
more  rapid  exhaustion  of  the  nervous  power.  This  sud- 
den invasion  of  disease  during  the  intense  heat  of  summer  in 
temperate  regions,  and  in  all  hot  countries,  among  those  not 
accustomed  to  them,  is  well  known.  The  consideration  of 
this  class  not  being  a  proper  subject  for  this  paper,  it  will  of 
necessity  be  passed  over ;  while  the  indirect  efl'ects,  or  such  as 
are  less  prompt  in  their  manifestation,  as  in  the  disease  now 
before  us,  will  form  the  proper  subject  for  investigation. 

There  is  one  organ  which  exhibits  before  all  others  the 
effects  of  heat,  and  that  to  a  remarkable  extent.  From  the 
earliest  period  the  liver  has  been  regarded  as  the  one  that 
suffers  most  from  this  cause  ;  and  a  host  of  writers  on  the  in- 
fluence of  tropical  climates  and  their  diseases,  refer  to  atmos- 
pheric heat  as  the  principal  source  of  hepatic  affections. 

Such  affections  prevail  to  so  great  an  extent  in  hot 
climates  that  those  who  have  practiced  in  temperate  regions 


Essay  on  Cholera  Infantum.  303 

alone,  will  find  it  difficult  to  belicA^e  in  their  extensive  preva- 
lence, among  natives  as  v^ell  as  among  strangers.  Although 
there  may  be  auxiliary  causes,  yet  it  is  by  the  most  accurate 
observers  attributed  to  atmospheric  heat  as  the  principal 
cause.  Thomas,  Johnson,  Moseley,  Saunders,  Larrey,  Fitz- 
patrick  and  others,  who  have  resided  in  hot  countries,  refer 
to  heat  as  the  agent  to  which  the  alterations  in  the  action  and 
organization  of  the  liver  are  to  be  attributed.  There  is  no 
other  organ  on  which  caloric  appears  to  be  concentrated  in  its 
efiects,  and  none  whereon  the  consequences  are  so  marked.* 

In  some  instances  an  active  condition  of  this  viscus  is 
produced,  marked  at  times  by  an  inordinate  secretion  of  bile ; 
in  many  of  them  a  want  of  action  ensues,  following  this  ex- 
cessive action  a?  a  state  of  collapse  follows  that  of  inordinate 
excitement. 

Among  the  effects  of  heat  on  the  liver  is  that  which  is 
denominated  chronic  inflammation.  This  term  appears  to 
have  been  applied  to  various  afiections  of  this  organ,  which 
differ  from  the  acute  or  active  inflammation.  A  score  of 
morbid  conditions  are  referred  to  chronic  inflammation. 
These  morbid  states,  it  is  plain,  may  differ  very  essentially 
from  chronic  inflammation,  and  yet  collectively  tliey  have 
been  so  denominated.  Among  these  derangements  is  found 
a  simply  sluggish  or  congested  state ;  when  it  becomes  slowly 
indurated,  with  or  without  enlargement,  and  when  it  no 
longer  performs  its  office  of  secretion  of  bile.  This  is  a  very 
common  condition  in  the  East  and  "West  Indies  ;  a  torpid 
condition  of  the  liver  and  a  paucity  of  its  biliary  secretion,  are 
very  frec|uent  disorders  in  those  places,  attended  with  consti- 
pation and  indigestion. 

These  are  the  consequences  of  disease  protracted  for  years ; 
but  in  affections  of  this  organ  arising  during  a  shorter  period, 
alterations  less  marked  are  to  be  looked  for ;  and  such  are 
revealed  in  cholera  infantum. 

*  Soe  Appendix,  J. 


30i  Essay  on  Cholera  Infantum. 

As  heat  exhibits  its  action  on  the  hepatic  system,  so  cold 
shows  itself  upon  the  respiratory  organs,  less  extensively ;  but 
it  is  much  more  decided  in  its  manifestations.  Affections  of 
the  liver  are  more  or  less  obscure  ;  as  this  organ  is  less  under 
our  cognizance,  both  in  its  condition  of  liealth  and  of  dis- 
ease, little  evidences  of  its  diseased  condition  exist,  and  ob- 
scurity and  uncertainty  often  attend  its  derangements,  both 
in  the  young  and  the  adult. 

Summer  and  winter  show  their  effects  very  promptly  on 
the  tender  and  susceptible  system  of  the  infant ;  the  winter 
not  among  so  many  individuals,  partly  perhaps  on  account  of 
the  ability  of  most  people  to  shield  themselves  and  their  off- 
spring from  the  extreme  cold,  while  from  the  intense  heat  of 
summer  there  is  no  escape. 

Infants  yield  quickly  to  the  influences  of  cold,  and  suffer 
greatly  from  affections  of  the  respiratory  organs  during  the 
winter;  while  there  is  no  marked  disease  among  them  during 
the  excessive  heat  of  summer,  unless  it  be  derangements  of 
the  chylopoetic  viscera.  The  "summer-complaint"  is  the 
popular  name  for  one  form  of  these  derangements,  from  its 
extreme  prevalence  during  the  existence  of  a  high  range  of 
temperature.  In  the  absence  of  any  facts  to  show  that  heat 
will  produce  a  decided  effect,  among  a  large  number  of  indi- 
viduals, on  any  other  part  of  the  system  than  the  hepatic,  it 
would  seem  to  be  but  reasonable  to  suppose  that  the  gland 
which  is  so  generally  affected  by  it  would  not  escape  in  the 
infant,  but  would  be  the  part  that  would  be  primarily  diseased 
under  the  circumstances  which  produce  so  violent  a  disorder 
as  cholera  infantum,  or  "  summer-complaint." 

The  first  effect  of  heat  upon  the  system  is  through  the 
lungs,  and  by  interfering  with  the  proper  discharge  of  the  res- 
piratory function  ;  this  act  being  the  introduction  of  oxygen 
during  inspiration,  and  the  ejection  of  carbonic  acid  during 
expiration.  It  has  been  proved  by  experiments  on  small 
animals,  that  a  much  less  amount  of  atmosplieric  air  is  de- 
composed during  hot  than  during  cold  weather.     In  an  expe- 


Essay  on  Cholera  Infantum.  305 

riment  by  Crawford,  it  was  found  that  a  guinea  pig  under  a 
temperature  of  55°  consumed  twice  tlie  quantity  of  oxygen 
than  when  confined  to  a  temperature  of  lOi". 

The  connection  of  the  process  of  respiration  with  affections 
of  the  liver,  will  be  considered  when  the  effects  of  the  next 
two  causes  are  examined, 

26?.  Excessive  atmospheric  humidity.- — This  is  one  of  the 
principal  causes  of  the  extreme  languor  in  hot  and  crowded 
places.  One  of  the  modes  by  which  extreme  moisture,  with 
heat,  acts  unfavorably  upon  the  body,  is  by  preventing  the 
ordinary  amount  of  exhalation  from  the  lungs.  This  is  most 
decidedly  seen  when  the  excess  of  moisture  arises  from  great 
crowding,  and  the  usual  domestic  occupations  in  houses  where 
several  families  reside.  The  houses  of  the  poor  are  loaded 
with  vapor  from  these  causes  ;  the  temperature  at  which 
moisture  is  deposited  scarcely  differing  from  that  of  the  air. 
We  have  tried  the  experiment  with  a  wet  bulb  thermometer 
where  the  temperature  was  at  90°,  and  could  not  make  the 
dew-point  lower  than  88°.  It  has  been  probably  often  at  the 
point  of  saturation,  when  they  will  both  range  at  the  same 
degree. 

The  air  always  contains  moisture,  and  in  proportion  to  the 
amount  is  the  quantity  of  moisture  exhaled  from  the  lungs. 
Thus,  air  containing  moisture  that  is  dej^osited  at  38°,  the  aver- 
age in  this  climate,  will  allow  of  a  much  greater  evaporation 
from  the  lungs  than  when  the  temperature  of  the  "dew-point" 
is  at  70°. 

It  is  shown  by  the  experiments  of  Dalton  that  the  quan- 
tity of  vapor  contained  in  a  cubic  inch  of  air  when  the  dew- 
point  is  at  88°,  is  .00166852  grain ;  when  at  94°  the  amount 
is  .00938243  grain.  The  last  mentioned  is  the  dew-point  of 
the  vapor  as  it  is  expelled  from  the  lungs,  whatever  may  be 
the  temperature  of  the  surrounding  air ;  and  this  is  the  amount 
of  vapor  contained  in  a  cubic  inch  of  air  as  it  passes  from 
the  lungs  of  an  adult.  If  the  air  before  inspiration  be  over- 
loaded wath  vapor,  it  is  obvious  that  it  must  prevent  to  a  cer- 
tain extent  the  depuration  from  the  lungs.      We  have  found, 


306  Essay  on  Cholera  Infantum. 

however,  that  unless  the  amount  of  vapor  in  the  air  very 
nearly  approaches  to  that  passed  from  the  lungs,  no  very 
marked  effects  are  produced,  but  a  sense  of  oppression  and 
suffocation  arises  when  it  approaches  that  point. 

The  weight  of  a  cubic  inch  of  vapor  at  88°  is  .00789288 
gr.  which  is  .00622436  more  than  the  mean  of  the  climate,  and 
.00158153  less  than  the  amount  contained  in  the  pulmonary 
vapor.  If  these  be  multiplied  by  1,152,000,  the  number  of  cubic 
inches  inhaled  in  a  day  by  an  adult,  according  to  Thompson, 
Minzies,  and  others,  the  result  will  be  respectively  7170  and 
1811  grains  ;  the  difference  between  the  two-5359  grains-will 
give  the  lessened  amount  of  transpiration  of  pulmonary  vapor. 
When  at  70°,  the  highest  in  this  climate,  the  weight  of  a  cubic 
inch  of  vapor  is  .00461639 ;  if  this  is  subtracted  from  .00938243, 
which  is  the  quantity  in  a  cubic  inch  of  respired  air,  it  will 
leave  .00476604, which  multiplied  by  1,152,000  will  give  5490^ 
grains  of  water  evaporated  from  the  lungs  when  the  air  is 
inhaled  at  a  dew-point  of  70°.  These  statements  will  show 
how  much  an  excessively  high  dew-point  must  interfere  with 
a  proper  depuration  from  the  lungs. 

Another  source  of  embarrassment  to  the  full  healthy  de- 
puration from  the  lungs  is  the  increased  elastic  force  of  vapor 
at  a  high  temperature.  According  to  Dalton,  this  power  at 
38°,  is  .264,  and  at  88°  1.286,  in  inches  of  mercury. 

There  are,  therefore,  two  obstacles  to  a  free  pulmonary  ex- 
halation in  an  inordinately  moist  state  of  the  air. 

The  lessening  also  of  the  transpiration  from  the  skin,  from 
the  same  causes,  has  an  important  influence  upon  the 
healthy  action  of  the  body,  as  is  known  by  daily  experience  ; 
but  the  arrest  of  cutaneous  depuration  by  means  of  exces- 
sive moisture  of  the  surrounding  air  differs  in  its  effects  from 
that  produced  by  cold. 

The  principal  results  of  an  arrest  of  the  ordinary  pulmo- 
nary depuration  is  to  cause  some  movement  of  compensation 
in  another  part;  the  consideration  of  wliich  will  be  deferred 
until  the  next  subject  has  been  investigated. 

Zd.  Malaria. — There  are  two  alterations  in  the  air  when- 


Essay  on  Cholera  Infantum.  307 

ever  there  exists  any  deterioration ;  one  is  the  chemical 
change,  and  the  other,  a  simple  mixture  of  foreign  and  dele- 
terious ingredients.  In  all  crowded  places  the  chemical 
change  must  be  principally  that  of  an  excess  of  carbonic  acid 
from  the  constant  respiration.  This  arises  from  the  process  of 
respiration  being  that  by  which  oxygen  is  introduced  into  the 
system  through  the  blood,  and  thereby  causing  in  the  ultimate 
tissues  the  combustion  of  carbon,  which  escapes  from  the 
lungs  as  carbonic  acid. 

According  to  the  experiments  of  MM".  Dulong  and  Des- 
pretz,  the  quantity  of  carbonic  acid  thus  produced  is  the  same 
as  would  result  from  the  combustion  of  an  amount  of  carbon 
equal  to  that  of  which  the  body  is  deprived  by  the  act  of  ex- 
piration ;  the  carbonic  acid  passing  into  the  surrounding  air, 
and  taking  the  place  of  the  oxygen  which  is  removed  by  in- 
spiration. By  respiration  alone,  an  adult  will  transform  into 
carbonic  acid  in  the  space  of  an  hour,  all  the  oxygen  contained 
in  twenty-five  gallons  of  atmospheric  air ;  which  in  a  house, 
and  especially  in  a  sleeping  apartment,  is  a  matter  of  great 
importance. 

From  this  process,  also,  arises  the  increased  heat  of  a  crowd- 
ed room ;  the  union  of  the  carbon  and  oxygen  producing  an 
additional  heat,  which  is  added  to  the  atmospheric  tempera- 
ture already  existing, — the  body  of  every  animal  being  a 
constant  generator  of  heat.  The  same  changes  occur  outside 
of  our  dwellings,  but  are  less  injurious,  from  being  more  easily 
diffused  and  dissipated. 

Another  change  in  the  surrounding  air  is  produced  by 
transpiration  both  from  the  skin  and  lungs.  It  is  a  mixture 
solely,  and  is  independent  of  any  chemical  change.  This 
addition  eludes  altogether  chemical  tests,  and  exists,  it  would 
seem,  only  as  suspended  in  the  atmosphere,  and  is  conveyed 
by  it  as  a  foreign  body,  or  rather  by  the  vapor  that  is  always 
present  in  the  air.  The  transparent  fluid  exhaled  from  the 
lungs  is  in  every  respect  the  same ;  the  taste  is  saltish,  the 
color  peculiar,  and  it  becomes  insupportably  offensive  when 


308  Essay  on  Cholera  Infantum. 

kept  in  a  warm  place ;  showing  that  it  consists  of  animal  mat- 
ter in  a  state  of  decomposition. 

The  perspiration  is  sometimes  differently  scented ;  it  has 
had  the  odor  of  musk,  violets,  sulphur  ;  and  it  has  also  been 
extremely  foetid  and  occasionally  acid.  It  has  also  been  vari- 
ously colored, — red,  saffron,  black,  or  blue. 

These  facts  would  appear  to  show  that  the  substances 
transpired  possess  properties  derived  from  the  body,  and  eject- 
ed as  not  proper  to  be  retained.  This  transpiring  process  is 
indeed  one  of  depuration,  and  to  the  extent  of  twenty-eight 
ounces  in  twenty-four  hours.  It  must  be,  therefore,  injurious 
to  be  receiving  into  the  body  by  inspiration  that  which  its 
necessities  have  previously  required  to  be  removed.  Who  but 
infants  would  be  the  greatest  sufferers  ?  a  class  among  which 
the  effects  of  external  influences,  of  whatever  kind,  are  so 
promptly  experienced,  and  to  which  they  so  promptly  yield. 

All  the  conditions  of  the  atmosphere  which  have  been  con- 
sidered, directly  interfere  with  the  ultimate  object  of  respi- 
ration, and  when  they  are  all  present  in  a  marked  degree,  the 
effects  will  sometimes  appear  in  the  embarrassment  of  the 
act  itself. 

When  any  organ  is  disturbed  in  the  exercise  of  its  appro- 
priate functions,  and  a  morbid  action  arises,  the  system  strug- 
gles, as  it  were,  for  relief;  and  under  this  derangement,  some 
other  will  be  found  either  to  be  involved  in  the  derangement, 
or  to  have  assumed  its  functions,  and  thereby  to  have  relieved 
the  morbid  condition  of  that  one  which  was  primarily  af- 
fected. 

This  is  of  so  ordinary  occurrence  that  when  a  morbid 
functional  change  arises,  we  naturally  look  for  a  vicarious 
movement,  which  either  affords  relief,  or  by  too  great  a  de- 
mand on  the  energies  of  the  body  for  that  purpose,  passes 
into  a  diseased  action  in  a  part  of  the  system  distant  from  that 
originally  affected.  Tliis  movement  of  compensation  is 
familiarly  illustrated  in  the  reciprocal  affections  of  the  skin 
and    kidneys,  skin  and  lungs,  etc.,  in   a  low  temperature. 


Essay  on  Cholera  Irtfanium.  309 

That  between  the  lungs  and  the  liver  is  no  less  remarkable, 
and  equally  important  in  its  results. 

When  the  air  becomes  unfit  for  the  necessary  renovation 
of  the  blood  through  the  medium  of  the  lungs,  or  when  the 
usual  amount  of  depuration  from  them  is  prevented,  their 
functions  are  but  imperfectly  performed,  and  the  requirements 
of  the  system  inadequately  supplied.  Under  this  condition, 
especially  when  the  interference  is  slight,  but  is  at  the  same 
time  protracted,  no  sudden  evidence  of  derangement  presents 
itself,  but  a  decided  action  will  be  established  in  a  part  that 
evidently  bears  a  reciprocal  relation  to  the  lungs.  This  part 
appears  to  be  the  liver,  for  the  following  reasons : 

According  to  the  experiments  of  Tiedemann  and  Gmelin, 
it  has  been  found  that  the  quantity  of  venous  blood  sent  to 
the  liver  increases  as  the  pulmonary  system  is  less  perfect. 
In  the  mammalia  the  vena  portse  conveys  blood  from  the  intes- 
tines alone  ;  in  reptiles  it  is  also  brought  from  the  posterior 
extremities,  tail,  kidneys,  and  other  parts.  In  connection  with 
this,  is  the  fact  that  the  temporary  suspension  of  the  functions 
of  the  lungs,  and  the  consequent  arrest  of  the  flow  of  blood 
through  them,  in  hybernating  animals  during  their  period  of 
sleep,  is  not  attended  by  a  suspension  of  the  functions  of  the 
liver,  bile  is  secreted  as  usual ;  corresponding  with  the  human 
foetus,  where  the  total  inactivity  of  the  lungs  appears  to  be 
compensated  by  some  action  of  the  liver. 

The  vicarious  action  of  the  liver,  is  also  manifest  in  the 
pathological  condition  of  that  organ  from  the  eflects  on  the 
respiratory  process.  Some  of  them  occur  in  malarial  districts, 
and  are  well  known  to  residents  of  those  places.  Hepatic 
diseases  aifect  hogs  and  sheep  that  are  exposed  to  paludal 
effluvia,  while  "gall  sickness  "  is  a  popular  designation  for 
similar  disorders  among  men.  One  of  these  results,  which 
exhibit  m  a  strong  light  the  connection  of  the  morbid  de- 
rangement of  the  lungs  and  liver  from  malaria,  is  the  compli- 
cation of  pneumonia  with  hepatic  disease,  known  as  bilious 
pneumonia. 

Another  illustration  of  the  vicarious  action   of  the  liver, 


310  Essay  on  Cholera  Infantum. 

wlien  the  functions  of  the  hmgs  are  impaired,  appears  in 
the  fact  that  fattj  livers  are  frequent  in  pulmonary  phthisis, 
of  which  M.  Louis  and  Dr.  Horner  give  several  examples. 
The  former  mentions  forty-nine  cases,  of  which  number  forty- 
seven  were  dependent  on  tbat  aflfection.  Fat,  it  is  well 
known,  abounds  in  carbon. 

That  morbid  hepatic  affections  will  arise  from  breathing 
in  a  confined  atmosphere,  where  the  lungs  are  forced,  to  re- 
ceive air  deprived  of  a  portion  of  its  oxygen,  appears  from 
the  results  that  have  followed  experiments  on  animals  purpose- 
ly confined,  where  the  air  could  not  be  freely  renewed.  Dr. 
Baron  placed  several  young  rabbits  where  they  could  not  ob- 
tain fresh  air,  feeding  them  on  cabbage  and  grass.  One  of 
them  died  in  a  month,  and  presented  a  morbid  condition  of 
the  liver,  consisting  principally  of  vesicles  over  its  external 
surface.  In  nine  days  another  died,  with  tubercles  in  the 
same  viscus.  In  four  days  another  died,  with  the  whole  of 
the  liver  diseased ;  and  in  two  days  another  died,  exhibiting  the 
liver  in  the  same  condition.  The  three  that  remained  were 
removed  to  an  open  situation,  and  recovered. 

Physiology,  and  the  comparative  anatomy  of  this  organ, 
support  the  opinion  that  it  does  perform  a  function  supple- 
mentary to  that  of  the  lungs,  and  that,  with  respect  to  the 
venous  blood  that  enters  it  by  the  portal  vein,  it  is  an  organ 
for  depuration,  being  the  only  one  in  the  body  in  connection 
with  the  lungs,  if  we  may  except  the  skin,  that  acts  in  remov- 
ing the  carbonic  acid  from  the  system.  The  skin,  however,  is 
very  limited  in  its  excretory  function  in  this  particular. 

That  which  appears  to  be  the  most  prominent  fact  when 
considering  the  external  causes  of  cholera  infantum  is,  that 
they  all  are  connected  with  some  interference  with  the  proper 
discharge  of  the  functions  peculiar  to  the  lungs,  and  conse- 
quently with  an  imperfect  removal  of  carbonic  acid  from  the 
system. 

The  importance  of  this  depurative  process  is  evident  from 
the  physiological  history  of  all  animals ;  they  all  require 
oxygen,  and  the  effect  of  its  use  is  uniformly  the  presence  of 


Essay  on  Cholera  Infantum.  311 

carbonic  acid  in  the  air,  with  which  they  are  surrounded, 
when  the  circumstances  are  such  as  to  prevent  the  results  of 
respiration  from  being  dissij)ated. 

It  cannot  be  supposed  that  whenever  so  general  a  law  of 
animal  nature  is  interfered  with,  the  system  would  retain 
its  healthy  vigor,  and  discharge  with  suitable  energy  its  varied 
functions.  It  would  seem  as  if  the  retention  of  carbonic  acid 
is  the  retention  of  an  effete  substance  possessing  peculiarly 
injurious  qualities,  and  which,  by  the  action  of  some  of  the 
organs,  must  be  removed.  So  virulent,  indeed,  is  the  poison, 
that  if  all  the  oxygen  is  removed,  so  as  to  preclude  the  possi- 
bility of  its  action  on  the  body,  speedy  death  ensues ;  if  a 
less  quantity  than  is  required  be  supplied,  uneasiness,  debil- 
ity, and  fainting  follow.  In  an  atmosphere  containing  more, 
but  still  less  than  would  satisfy  the  requirements  of  the  body, 
a  protracted  derangement  of  one  or  more  of  the  organs  is  the 
result. 

Now,  the  lungs  perform  the  function  of  relieving  the  sys- 
tem from  this  pernicious  ingredient ;  and  all  the  causes  which 
have  been  considered  do,  each  in  its  own  way,  interfere  with 
this  process.  Thus,  it  has  been  proved  by  direct  experiment 
on  small  animals,  that  a  lessened  consumption  of  oxygen  oc- 
curred as  the  temperature  increased,  and  that  a  difference  of 
49°  made  a  difference  of  one  half  of  the  amount  consumed. 
Excessive  humidity  added  to  this  high  temperature,  also  in- 
terferes with  the  proper  action  of  the  lungs,  by  preventing  a 
full  exhalation.  Malaria,  especially  in  crowded  places,  also 
interferes  with  the  function  of  respiration,  by  supplying  air 
deficient  in  oxygen,  and  charged  also  with  foreign  ingredients. 
All  these  causes  of  the  disease  unite  in  interfering  with  the 
normal  results  of  respiration,  either  by  rendering  the  air  defi- 
cient in  what  may  be  denominated  the  vital  ingredient,  or  by 
some  physical  modification  which  prevents  a  sufficient  quan- 
tity from  being  inhaled. 

There  being  no  proof  that  the  active  causes  of  cholera 
infantum  directly  affect  the  mucous  membrane  of  the  intes- 
tines, but  abundant  evidence  that  they  do  produce  a  morbid 


812  Essay  on  Cholera  Infantum. 

change  in  the  liver,  this  organ  is  probably  the  first  of  the 
abdominal  viscera  that  is  afiected  in  the  disease,  by  the  esta- 
blishment of  a  vicarious  action  ;  the  Imigs  not  freely  reliev- 
ing the  system,  and  the  liver  being  a  supplementary  organ 
performing  a  part  of  their  functions. 

The  transition  from  an  over-excited  state  of  this  organ  to 
one  of  collapse  or  congestion,  and  to  other  morbid  conditions, 
is  a  subject  familiar  to  every  medical  practitioner,  and  requires 
no  illustration. 

The  morbid  state  of  the  mucous  surface  of  the  intestines 
follows  next,  being  the  result  of  the  morbid  condition  of  the 
liver,  as  will  appear  when  the  influences  of  the  fourth  cause 
are  considered. 

Uh.  Period  of  Life. — ^This  may  be  regarded  as  the  pre- 
disposing cause,  for  the  disease  never  appears  but  during  the 
period  of  teething.  When  children  that  have  passed  that 
epoch  are  exposed  to  the  causes  already  considered,  the  re- 
sult is  dysentery.  This  the  writer  has  repeatedly  seen  in  the 
same  house,  during  a  hot  season,  where  cholera  infantum  has 
prevailed.  When  the  affection  of  the  bowels  that  was  excited 
in  the  older  children  continued  for  a  few  days,  it  always  as- 
sumed the  form  of  dysentery,  but  never  that  of  the  peculiar 
disease  of  infancy. 

When  the  morbid  condition  of  the  intestines  was  stated,  it 
was  shown  that  the  source  of  the  flow  was  the  mucous  folli- 
cles that  studded  the  greater  part  of  the  intestinal  surface,  and 
that  these  follicles  presented  an  appearance  of  inordinate  de- 
velopment, inflammation,  and  ulceration.  Their  development 
is  peculiar  to  the  period  of  life  at  which  cholera  infantum  ap- 
pears, is  the  result  of  the  natural  movement  of  the  system, 
and  is  simultaneous  with  the  eruption  of  the  teeth.  The  in- 
flammation and  ulceration  of  the  follicles  are  superadded 
morbid  action,  constituting  the  disease  under  consideration. 

In  the  infant  and  child,  the  active  process  of  development 
is   an   important   predisposing  cause  of  disease.     In  them' 
everythinji;   predominates    that    is   connected   with   organic 
growth.    The  desire  for  food  is  frequent,  the  digestion  rapid, 


Essay  on  Cholera  Infantum.  313 

the  blood  and  fluids  are  in  excess  ;  capillary  action,  secretion, 
and  interstitial  increase  proceed  with  great  vigor  ;  while  the 
nervous  sensibilities  are  in  high  activity.  Growth  of  parts 
seems  in  truth  to  differ  from  inflammation  only  in  degree, 
which  may  very  speedily  be  induced  upon  any  disturbance 
of  the  developing  process. 

It  has  been  remarked  that  infants  grow  more  during  the 
first  year,  the  increase  becoming  less  rapid  as  the  child  ap- 
proaches the  fourth  or  fifth  year  ;  and  it  is  well  known  that 
during  the  first-mentioned  period,  violent  disease  and  sudden 
mortality  more  frequently  occur  than  at  any  other  time  of 
life.  Here,  then,  is  a  direct  relation  subsisting  between  the 
rapid  increase  of  the  body  and  its  tendency  to  severe  and 
fatal  disease  ;  the  naturally  exalted  action  of  the  capillaries 
in  developing  a  part  being  easily  made  to  pass  the  boundaries 
of  the  healthy  process  of  growth,  and  become  the  active 
agents  of  inflammation  ;  the  effects  of  which  are  of  marked 
peculiarity, — prompt  serous  effusions  from  some  membranes, 
and  in  others  the  exudation  of  lymph,  as  in  the  trachea  in 
inflammations  of  that  tube. 

The  diseases  of  the  brain  furnish  an  evidence  of  the  tran- 
sition from  health  to  disease  during  the  process  of  growth ;  it 
is  well  known  that  at  the  time  of  birth  the  cerebral  organ, 
although  large,  is  exceedingly  imperfect  in  its  organization, 
consisting  of  a  mass  almost  like  jelly.  It  is  not  complete  in 
its  parts  until  a  year  or  more  has  elapsed,  during  which  period 
the  vital  energy  of  the  part  is  in  great  activity,  carrying  on 
the  process  of  development.  Congestions,  effusions,  and  con- 
vulsions, are  more  common  at  this  time  than  at  any  other. 

In  other  instances  there  is  an  excess  of  action  in  one  set 
of  organs,  which  gives  a  preponderance  of  one  system  over 
others,  as  in  the  lymphatic ;  producing  congestions  and  ob- 
structions in  the  different  glands  of  the  body. 

Another  illustration  of  the  effect  of  the  development  of 
parts  in  the  production  of  disease,  is  that  afforded  by  the 
mucous  follicles  of  the  intestines.  When,  in  the  order  of  the 
natural  development  of  the  infant's  frame,  these  follicles  for 


314  Essay  on  Cholera  Infantum. 

the  first  time  show  themselves  in  connection  with  other  parts 
concerned  in  nutrition,  they  are  in  a  high  state  of  activity, 
pouring  forth  an  abundance  of  their  natural  secretion.  Thus 
far  the  action  is  a  natural  one,  and  one  of  health.  Should  it 
become  excessive,  a  serous  diarrhoea  takes  its  place,  demand- 
ing the  interference  of  the  physician  for  its  removal.  This 
same  condition  of  the  development  of  the  follicles,  when  com- 
plicated with  other  derangements  of  the  system,  and  kept  in 
a  state  of  morbid  activity  by  the  continual  operation  of  cer- 
tain exciting  causes,  terminates  in  producing  one  of  the  most 
fatal  diseases  of  our  climate,  the  cholera  of  infants. 

Dissections  of  infants  that  have  died  of  various  diseases, 
have  exhibited  the  development  of  the  mucous  follicles,  com- 
mencing at  the  time  of  the  appearance  of  the  teeth,  while 
before  that  time  they  are  rarely  to  be  seen.  Numerous  post- 
mortem examinations*  show  that  the  follicles  experience  an 
increase  of  vital  energy  which  augments  their  secretion,  and 
renders  their  size  larger  and  their  number  greater,  but  which 
still  does  not  produce  any  redness,  tumeftiction,  or  ulceration. 
Their  activity  in  secretion  during  the  time  of  dentition  is  the 
true  cause  of  the  ordinary  diarrhoea  in  teething  infants,  usu- 
ally ascribed  to  sympathy  with  the  gums,  and  which  to  a 
moderate  degree  is  not  to  be  regarded  as  disease,  but  is  the 
result  of  the  physiological  action  of  the  period  of  life. 

The  follicles,  in  the  natural  course  of  development,  having 
just  passed  into  a  state  of  activity,  are  thereby  prepared  to 
have  an  additional  or  excessive  development,  on  the  applica- 
tion of  a  sufficient  cause ;  and  then  the  transition  is  both  rapid 
and  easy  from  a  healthy  to  a  diseased  state. 

The  normal  follicular  action  passing  into  an  abnormal 
state,  under  the  influence  of  the  three  atmospheric  causes  of 
the  disease,  is  effected  through  the  agency  of  the  liver ; 
which,  we  have  seen,  is  the  part  on  which  all  these  causes  ex- 
ercise their  power.  They  produce  disease  and  alterations  in 
its  density  or  texture,  and  thereby  the  passage  of  blood  that 

*  Billard,  Malad.  des  Enf.,  p.  306. 


Essay  on  Cholera  Infantum.  315 

is  returned  through  it  from  the  intestinal  surface  is  obstruct- 
ed. Congestion  of  the  mucous  membrane  and  its  follicles 
takes  place,  and  nature  seeks  relief  by  an  inordinate  secre- 
tion from  them,  already  in  an  exalted  state  of  action.  When 
morbid  action  is  once  established,  congestion,  inflammation, 
or  ulceration  is  the  course  naturally  to  be  expected. 

It  appears,  therefore,  that  cholera  infantum  is  a  disease 
connected  with  the  development  of  the  body,  and  is  the  most 
remarkable  instance  of  the  relation  subsisting  between  the 
growth  of  parts  and  the  diseases  of  childhood  and  infancy. 
The  effect  of  growth  shows  itself  in  the  violence  of  inflam- 
matory diseases,  as  connected  with  the  exalted  state  of  inter- 
stitial nutrition,  so  characteristically  rapid  at  an  early  period 
of  life.  At  one  time,  it  is  exhibited,  as  we  have  seen,  in  a 
peculiar  exudation  from  the  blood,  abounding  in  fibrin,  as 
in  croup  ;  again,  in  the  morbid  action  connected  with  the 
changes  in  the  cerebral  organ  ;  at  another  time,  in  the  suc- 
cession of  diseased  action  of  the  different  parts  of  the  glandu- 
lar system ;  and  in  the  disease  now  under  investigation,  in 
the  morbid  development  of  the  mucous  follicles  of  the  intes- 
tines during  the  period  of  second  infancy. 

bth.  Ina/piwojpriate  food. — ^There  is  little  to  be  said  upon 
the  action  of  food  that  is  digested  with  difficulty.  The  por- 
tion not  disposed  of  by  the  action  of  digestion  becomes,  it  is 
well  known,  an  irritating  body,  which,  of  course,  must  irritate 
all  the  parts  through  which  it  passes.  That  kind  of  food 
which  is  the  most  quickly  absorbed  is  least  likely  to  add  to 
the  causes  already  in  operation  to  develop  the  disease,  which 
must  be  promoted  by  intestinal  indigestion. 

S  EMEIO  LOGY  . 

The  division  of  diseases  into  different  stages,  is  both  natu- 
ral and  useful.  Like  all  other  natural  phenomena,  disease 
has  its  peculiar  signs  in  its  incipiency,  maturity  and  decline ; 
exhibiting  phases  which  indicate  the  kind  of  interference 
which  it  is  necessary  to  adopt  in  its  management.    Without 


316  Essay  on  Cholera  Infantum. 

availing  ourselves  of  these  as  a  guide,  the  practical  employ- 
ment of  remedies  would  be  equally  unscientific  and  unsafe. 
The  boundaries,  however,  of  the  different  stages  do  not  always 
appear  so  distinct  as  to  enable  us  to  detect  clearly  the  pro- 
gress of  the  disease  from  one  to  the  other,  and  the  complica- 
tions add  their  influence  in  rendering  the  actual  knowledge 
of  the  condition  of  the  affected  parts  obscure,  and  thereby 
often  tend  to  embarrass  the  judgment. 

Cholera  infantum,  in  its  progress,  appears  in  three  differ- 
ent conditions  or  stages.  The  first  is  marked  by  an  increased 
activity  of  the  bowels,  the  second  by  inflammation  and  ulcer- 
ation, and  the  third  by  complications. 

The  evacuation  in  the  first  stage  consists,  at  the  beginning, 
of  the  usual  fsecal  matters,  more  largely  mixed  with  watery 
fluid  than  in  health.  Indeed  when  the  disease  is  gradual  in 
its  invasion,  no  difference  will  be  observed  between  it  at  the 
early  stage  and  the  diarrhoea  of  teething  infants,  which  al- 
ways precedes  cholera  infantum,  and  is  in  truth  its  commence- 
ment. The  discharges  consist  largely  of  serum,  mixed  with 
mucus  or  minute  shreds,  or  colored  with  bile  ;  but  in  all  its 
forms  it  is  characterized  by  copious  watery  evacuations, 
which,  at  the  period  of  teething,  are  often  so  abundant  and  de- 
bilitating, that  the  child  is  in  a  few  days  exceedingly  emacia- 
ted and  exhausted.  This  is  probably  the  form  that  is  known 
as  the ''  watery  gripes  "  in  England,  when  it  has  not  passed  into 
the  decided  morbid  condition  which  will  be  more  particularly 
noticed  as  the  second  stage. 

To  a  moderate  extent,  diarrhoea  at  the  time  of  teething  is 
salutary  ;  should  it,  however,  increase  in  severity,  and  exhibit 
a  diminution  of  bile,  we  may  regard  this  increased  action  of 
the  mucous  follicles  as  evidence  of  the  congestion  of  the  mu- 
cous surface  of  the  intestines,  from  some  degree  of  congestion 
of  the  liver;  the  morbid  action  of  both  these  parts  being  the 
pathological  condition  of  cholera  infantum. 

Although  for  the  most  2>art  serous,  the  consistency  of  the 
passages  will  often  differ  in  the  course  of  the  day, — sometimes 
thick  and  pasty,  or  frothy,  at  other  times  bearing  a  resem- 


Essay  on  Cholei'a  Infantum.  317 

blance  to  the  yolk   of  a  hard-boiled  q^^  beaten  up   with 
water. 

This  diarrhoea  affects  the  system  both  by  the  debilitating 
effects  of  the  increased  peristaltic  action  and  by  the  prostra- 
tion occasioned  by  the  great  secretion  from  the  mucous  sur- 
face. 

In  this  diarrhoea  the  color  of  the  discharges  will  be  differ- 
ent, not  only  in  different  individuals,  but  also  various  in  the 
same  patient  at  different  times  of  the  day — yellowish,  light 
green,  or  of  the  peculiar  color  of  serum,  and  equally  as  trans- 
parent. This  last  condition  we  have  frequently  seen,  and  so 
destitute  of  any  additional  substances,  as  to  have  been  mis- 
taken by  the  nurse  for  the  urinary  discharge,  and  the  fact 
mentioned  of  the  excessive  amount  of  urine  passed  by  the 
child,  when  in  truth  there  had  been  none. 

It  is  rare  that  vomiting  occurs  very  early  in  the  disease  ; 
yet,  when  it  arises  simultaneously  with  the  first  appearance  of 
excessive  purging,  the  disease  is  proportionately  severe,  and 
exhaustion  and  death  will  often  ensue,  without  any  complica- 
tion, in  a  very  short  time.  "We  have  witnessed  death  under 
these  circumstances  in  twelve  hours.  Such  instances,  how- 
ever, are  rare,  and  it  is  umisual  for  a  fatal  termination  to  occur 
during  the  first  stage. 

The  vomiting,  or  efforts  at  vomiting,  is  a  marked  feature  of 
the  disease.  All  observers  must  have  noticed  its  obstinacy  and 
the  peculiar  kind  of  action  attendant  on  the  attempts  at  vom- 
iting. This  effort  is  sometimes  connected  with  a  powerful  ac- 
tion of  the  abdominal  muscles ;  and  they  will  be  found  at  times, 
on  placing  the  hand  over  the  abdomen,  to  be  in  a  convulsive 
or  rolling  motion,  generally  simultaneous  with  the  action  of 
the  stomach.  At  other  times  when  the  disease  is  severe,  this 
movement  of  the  muscles  will  take  place  without  any  at- 
tempts at  ejecting  any  thing  until  the  paroxysm  is  about  end- 
ing, when  the  efforts  to  vomit  will  occur. 

The  tongue  is   moist,  and  covered  with  fur  of  a   light 
brown  hue  at  its  base.      The  thirst  is  invariably  very  great. 
The  febrile   condition  does  not  arise  from  an  essential  or 
23 


318  Essay  on  Cholera  Infantum. 

primary  fever,  but  is  clearly  of  the  class  of  irritative  fevers; 
it  rarely  appears  at  the  beginning,  but  increases  with  the  pro- 
gress of  the  disease,  occurring  in  irregular  paroxysms  of  dif- 
ferent degrees  of  intensity.  The  heat  of  the  surface  of  the 
body  augments  in  the  course  of  the  disease,  especially  in  the 
abdominal  region. 

The  pulse  is  small,  quick,  and  frequent,  sometimes  sharp 
and  wiry. 

The  second  stage  is  the  period  of  inflammation  and  ulcera- 
tion. Tlie  general  heat  of  the  body  decreases,  while  that  of 
the  abdominal  surface  increases  to  a  high  degree  of  intensity. 

The  tongue  is  parched  and  heavily  laden  with  petechia  at 
the  sides  and  at  the  commissure  of  the  lips.  The  child  seizes 
with  frantic  eagerness  any  drink  that  may  be  offered. 

The  serous  diarrhoea  increases,  with  great  variety  in  the 
appearance  of  the  evacuations,  and  with  the  addition  of  mu- 
cus. While  before,  the  predominating  color  was  yellow, 
it  is  now  frequently  of  various  hues  of  green.  At  times  the 
serum  appears  to  be  replaced  by  masses  of  mucus,  of  a  greenish 
tinge  to  a  deep  hue  of  that  color.  Although  a  yellow  or  green 
color  may  indicate  the  presence  of  bile,  yet  the  alvine  evacu- 
ations may,  in  disease,  assume  this  appearance  without  the 
presence  of  bile.  The  jelly-like  mucus  derives  its  color  from 
the  alterations  in  the  secretion  produced  by  inflammation,  as 
is  occasionally  found  in  mucous  discharges  in  disease  in  other 
parts  of  the  body.  In  bilious  evacuations,  there  is  a  decidedly 
faecal  odor  ;  in  the  colored  mucus,  none.  The  color  is  also 
changed  to  a  brown  or  white,  and  frequently  pink.  During 
their  evacuation  the  usual  fs&cal  matter  is  retained. 

These  discharges  are  at  times  peculiarly  offensive,  at  other 
times  they  exhibit  no  other  odor  than  that  which  is  derived 
from  acid.  The  offensive  odor  is  not  that  of  ordinary  faeces, 
but  of  the  nature  which  attends  the  decompositions  of  animal 
tissues  in  ulceration  and  sloughing 

The  evacuations  present  different  appearances,  according 
to  the  part  of  the  intestines  the  most  affected  ;  thus  when  the 
upper  part  is  that  principally  diseased,  they  are  frothy  and 


Essay  on  Cholera  Infantum.  319 

acid,  and  when  the  food  is  passed,  it  appears  almost  unaltered 
by  the  process  of  digestion.  When  the  lowest  portion  of  the 
intestines  is  the  part,  the  disease  bears  a  resemblance  to  dys- 
entery, and  the  evacuations  are  bloody  and  slimy,  and  attend- 
ed with  tenesmus  and  pain. 

In  inflammatory  afflictions  of  the  bowels  in  children, 
there  is  always  some  sympathetic  affection  of  the  brain  ;  and 
serious  disease  of  this  organ  will  follow  an  inflammation  in 
the  digestive  system  ;  a  fact  well  known  to  the  ancients,  but 
more  particularly  pointed  out  by  modern  observers.  These 
pathological  sympathies  are  in  general  proportionate  to  the 
violence  of  the  primary  disease,  and  are  indeed  so  uniform 
that  the  meninges  of  the  brain  participate  in  an  equal  degree 
with  the  affections  of  the  bowels,  having  at  one  time  an  acute 
and  at  another  a  chronic  action.  The  brain,  in  confirmed 
cholera  infantum,  never  escapes. 

When  the  disease  has  proceeded  thus  far,  the  general 
aspect  of  the  child  is  that  of  distress  from  pain  in  the  head  as 
well  as  in  the  abdomen,  indicated  by  the  lineaments  of  the 
face.  Pain  is  indicated  as  existing  in  the  abdomen  by  a 
pinched  expression  of  the  face,  by  a  fold  in  the  commissure  of 
the  lips  outside  of  the  orbicularis  muscle,  and  by  a  lineament 
extending  from  this  part  to  the  inside  of  the  alse  nasi,  and 
sometimes  surrounding  the  orbicularis  muscle.  Pain  in  the 
head  is  known  by  a  frequent  corrugation  of  the  skin  below 
the  eye-brows.  These  most  usually  occur  upon  the  awaking 
of  the  child,  and  will  continue  for  a  minute,  or  shorter  period, 
before  it  evinces  pain  by  crying.  Added  to  these,  the  languor, 
paleness,  sunken  eyes,  with  their  dark  areola  and  general 
shrunken  condition  of  the  body,  complete  a  picture  of  distress 
which  it  is  in  vain  to  attempt  to  describe. 

The  third  stage  is  that  of  complication  and  death. 

The  skin  becomes  dry  and  ash-eolored.  It  hangs  loose,  in 
folds,  about  the  body,  while  over  the  forehead  it  is  tight  and 
smooth.  The  cheeks  become  shriveled,  and  the  general  as- 
pect of  the  cheeks  and  lips  imparts  an  appearance  of  old  age, 
while  the  muscles  in  every  part  of  the  body  are  flabby,  and 


320  Essay  on  Cholera  "Infantum. 

friglitfullj  attenuated.  The  eyes  are  strained,  and  the  adnata 
are  injected ;  drowsiness,  stupor,  and  partial  paralysis  suc- 
ceed, to  be  followed  by  death  after  a  protracted  term  of 
suffering. 

Such  is  the  usual  course  of  the  development  of  the  disease 
in  its  progress  to  a  fatal  termination,  "When  it  does  not  reach 
the  stage  of  complication,  it  is  often  exceedingly  protracted ; 
and  when  the  usual  secretions  are  to  a  certain  extent  restored, 
it  assumes  more  of  a  mixed  character,  resembling  a  chronic 
diarrhoea,  and  is  as  obstinate  and  as  diflScult  to  manage  as 
any  disease  of  childhood ;  terminating  fatally  from  mere 
exhaustion. 

The  discharges  frequently  change  their  character — be- 
coming serous,  mucous,  flaky,  bilious,  and  purulent,  by  turns. 
This  chronic  diarrhoea  affects  the  system  both  by  the  debilita- 
ting effects  of  the  irritation  of  a  large  diseased  surface,  and 
by  the  uninterrupted  secretion  from  the  mucous  membrane ; 
to  which  may  be  added  the  almost  total  loss  of  the  power 
of  digestion.  Whatever  is  the  character  of  the  alvine  evacua- 
tions, a  want  of  tone  in  the  affected  parts  appears  to  be  their 
pathological  condition,  with  occasional  ulceration  of  them. 

Treatment. 

In  the  treatment,  it  must  be  kept  in  mind  that  the  use  of 
therapeutic  means  is  of  little  avail  while  the  active  agents  in 
the  production  of  the  disease  are  in  continued  action  upon 
the  system.  Often  have  we  experienced  how  disheartening 
it  is  to  be  required  to  administer  medicine  for  the  cure  of  this 
disease,  when  the  circumstances  of  the  patient  are  such  as  to 
preclude  the  possibility  of  applying  to  any  extent  the  meas- 
ures demanded  by  the  laws  of  our  physical  nature.  Even 
the  temporary  relief  sought  during  the  day  is  productive  of 
little  benefit  by  a  return  at  night  to  the  close  and  stifling  air 
of  the  over-crowded  dwelling. 

To  exhibit  by  facts  in  as  strong  a  light  as  is  in  our  power, 


Essay  on  Cholera  Infantum.  321 

the  important  influence  exerted  by  a  pure  atmosphere  in 
overcoming  the  morbid  action  in  this  disease,  we  will  give 
the  results  of  several  cases;  those  only  of  a  large  number, 
occurring  both  in  public  and  private  practice,  of  which  we 
have  any  memoranda.  The  circumstances  under  which  they 
happened  were  so  marked,  as*  to  admit  of  their  being  divided 
into  three  classes. 

Of  ninety-four,  forty-four  occurred  where  the  concentrated 
effluvia  of  about  five  times  more  people  than  ought  to  have 
occupied  the  space  of  their  dwellings,  existed,  in  addition  to 
the  refuse  produced  by  them.  The  odor  of  the  air  was  at  all 
times  distinctly  offensive  to  the  senses  amidst  the  stifling  heat 
of  the  weather.  Of  these  forty-four,  twenty  died.  The  next 
class  occurred  among  persons  possessing  the  ordinary  com- 
forts of  such  as  usually  apply  at  the  dispensaries,  and  w^ere 
about  half  as  much  crowded  as  those  already  mentioned  ; 
they  numbered  thirty-five  ;  of  whom  ten  died.  The  last  con- 
sisted of  private  patients,  and  numbered  fifteen  ;  of  these, 
two  died. 

Could  we  add  to  these  numbers,  it  would,  without  doubt, 
add  an  abundant  testimony  in  corroboration  of  the  prevailing 
opinion  of  the  necessity  of  pure  air  as  a  curative  agent. 

Both  as  a  preventive,  and  as  a  remedy  when  the  disease 
exists,  it  will  be  necessary  to  adopt  suitable  means  to  modify 
the  excessive  heat  and  to  purify  the  vitiated  air.  It  is  indeed 
difiicult,  if  not  impossible,  among  such  as  are  exposed  to  the 
sufferings  and  have  to  endure  the  privations  of  poverty,  to 
accomplish  any  thing  of  this  nature.  An  attempt,  however, 
may  be  made  by  exposing  the  child  daily  tcrthe  reviving  in- 
fluences of  the  fresh  air,  hy  a  walk  in  the  suburbs,  or  if  the 
situation  permit,  by  an  excursion  on  the  water.  The  causes 
of  the  disease  are  clearly  obvious ;  and  these  measures  it  is 
the  duty  of  all  physicians  to  urge,  during  the  intense  heat  of 
summer,  that  nothing  may  be  omitted  in  the  way  of  prevent- 
ing so  formidable  and  fatal  a  scourge. 

It  is  surprising  how  often  is  witnessed  among  the  more 
intelligent,  who  are  removed  from  the  effects  of  poverty,  an 


322  Essay  on  Cholera  Infamtum. 

entire  disregard  of  the  simplest  rules  of  hygiene.  Frequently 
we  have  seen  young  children  suffering  from  the  effects  of 
heat  and  impure  air,  languid  and  sweating,  from  being 
crowded  in  one  bed  or  in  one  room  while  the  external  air  is 
carefully  excluded.  Placing  children  to  sleep  in  a  low  bed- 
stead that  has  been  kept  throughout  the  day  beneath  another, 
and  only  brought  out  at  night,  is  fraught  with  the  direst  of 
evils,  never  thought  of  by  those  having  the  immediate  care  of 
the  children. 

There  is  no  difficulty  among  those  whose  condition  in  life 
enables  them  to  use  the  simple  prophylactic  means  necessary, 
to  anticipate  this  and  other  affections  of  children  that  arise 
from  heat  and  impure  air.  The  doors  of  all  the  bedrooms 
should  be  left  open,  while  the  upper  sash  of  the  window  should 
be  let  down ;  no  danger  can  arise  from  the  external  air  ad- 
mitted in  this  way,  if  the  bed  is  removed  from  the  direct 
current.  During  the  day,  in  summer,  the  freest  circulation 
ought  to  be  encouraged  by  keeping  opposite  windows  open. 

Children  should  never  sleep  on  a  feather  bed :  a  hard  mat- 
rass that  will  not  accumulate  the  heat  is  the  only  kind  of  bed 
they  should  use  ;  while  the  body  ought  to  be  lightly  covered. 

The  prostrating  effects  of  heat  in  summer  are  particularly 
distressing  to  young  children,  in  whom  the  activity  of  the 
nutritive  process  is  great ;  and  in  proportion  to  this  activity 
of  the  capillary  system,  is  the  demand  for  fluid ;  while  the 
increased  cutaneous  excretion  increases  greatly  this  demand 
for  fluid,  l^othing  will  supply  this  necessity  so  well  and  be 
so  refreshing,  as  a  draught  of  cold  water.  All  persons  have 
experienced  this*desire  ;  and  the  uneasiness  and  fretfulness 
of  young  children,  who  are  unable  to  express  their  wants  in 
any  other  way,  arise  very  often  from  intense  thirst,  which 
nothing  will  quench  but  cold  water.  To  allay  this  irritabil- 
ity, is  itself  of  importance,  and  they  may  often  be  calmed  at 
night  by  a  drink  of  water.  This  we  have  always  placed 
among  the  general  preventive  measures. 

Diet  is  a  very  important  subject,  both  in  the  prevention 
and  management  of  the  disease.     One  of  the  greatest  evils  in 


Essay  on  Cholera  Infantum.  323 

its  treatment  is  the  use  of  vegetable  food,  either  of  a  farina- 
ceous or  starchy  nature.  The  last  mentioned,  so  often  given 
in  the  form  of  arrow-root  on  account  of  its  soft  mucilaginous 
consistency,  is  especially  objectionable.  All  vegetable  sub- 
stances are  unsuited  to  young  infants  ;  but  those  of  an  amyla- 
ceous nature  being  altogether  insoluble,  are  with  difficulty  ab- 
sorbed, and  when  the  mucous  membrane  is  diseased,  scarcely 
ever  are,  but  pass  as  foreign  substances  quite  through  the 
bowels,  and  may  be  detected  in  tlie  discharges  by  iodine,  the 
usual  test  for  starch.  Farinaceous  articles  are  very  likely  to 
become  acid,  and  excessively  so  in  this  disease.  We  regard 
all  such  articles  for  food  in  early  infancy  as  highly  pernicious, 
whether  the  child  be  sick  or  well. 

The  food  that  nature  supplies  is  the  best,  and,  if  there  is 
no  deterioration  either  in  quantity  or  quality,  should  be  the 
only  food  given.  When,  for  any  reason,  it  is  necessary  to 
make  a  substitute  for  it,  milk  properly  prepared  for  the  child 
should  still  be  given.* 

In  cholera  infantum,  we  have  been  in  the  habit  of  combin- 
ing a  solution  of  gelatine  with  the  milk,  as  the  most  appro- 
priate food  for  the  child ;  and,  where  the  stomach  is  excessively 
irritable,  to  give  nothing  for  a  while  but  the  jelly,  prepared 
thick  or  thin,  as  the  child  will  take  it  the  most  freely.  The 
use  of  this  substance  has  so  frequently  been  followed  by  deci- 
ded benefit,  that  we  regard  it  as  a  valuable  remedy.  It'  gela- 
tine comes  under  the  class  of  respiratory  food  only,  then  it 
must  be  regarded  as  a  therapeutic  agent.  It  is  so  perfectly 
soluble  that  it  is  absorbed  as  easily  as  water,  and  no  doubt 
has  passed  into  the  circulation  before  it  could  reach  the  dis- 
eased part ;  in  which  respect  it  contrasts  very  remarkably 
with  arrow-root,  so  frequently  given  in  this  disease. 

As  regards  the  indications  of  a  want  of  proper  nourishing 
or  stimulating  power  in  the  nurse's  milk,  we  have  been  much 
in  the  habit  of  being  guided  by  the  instincts  of  the  child, 
which  will  cause  it  at  times  eagerly  to  seize  some  animal  sub- 
stance and  suck  it  with  avidity.     Following  this  suggestion, 

*  See  Appendix,  K. 


324  Essay  on  Cholera  Infantum. 

we  have  directed  cow's  milk  to  be  given,  either  diluted, 
pure,  01-  combined  with  gelatine,  changed  occasionally  for 
chicken  water,  and  when  the  child  is  especially  eager  for 
animal  food  and  has  suffered  much  from  debility,  beef  tea 
or  a  piece  of  fat  pork,  according  to  the  instinct  of  the  child. 
These  last-mentioned  articles,  and  even  salted  meat,  are  espe- 
cially beneficial  in  the  more  advanced  forms  of  the  disease 
and  during  convalescence.  Iji  some  form  animal  substances 
are  necessary  in  every  stage. 

Like  all  other  obstinate  diseases,  cholera  infantum,  is  not 
without  its  specific  remedies.  In  succession,  alkalies,  qui- 
nine, the  stronger  mineral  acids,  nitrate  of  silver,  acetate  of 
lead,  oil  of  turpentine,  etc.,  have  been  reported  as  invaluable 
in  the  treatment  of  this  disease ;  some  of  them  administered 
for  the  accomplishment  of  a  definite  object,  and  some,  ap- 
parently upon  no  medical  principles  whatever.  When 
given  as  specifics,  they  have  all  in  their  turn  disappointed 
the  practitioner,  and  the  necessity  of  less  reliance  on  the  re- 
ported efficacy  of  some  one  agent,  and  of  more  upon  the  indi- 
cations of  a  correct  theory,  becomes  more  evident  in  propor- 
tion to  a  more  extended  experience  in  their  employment.  It 
is  by  no  means  intended  to  question  the  accuracy  of  the  state- 
ments made  as  to  the  success  of  these  various  articles ;  but  the 
numerous  failures  in  other  hands,  show  clearly  that  the  dif- 
ferent modifications  of  the  disease  in  different  places,  or  the 
use  of  the  remedy  under  other  conditions  of  the  system  than 
that  in  which  it  was  successfully  employed,  such,  for  instance, 
as  a  different  stage  of  development,  have  doubtless  been 
the  reasons  for  want  of  success  of  a  medicine  which  perhaps 
has  been  so  much  extolled,  as  to  convey  the  idea  that  the 
remedy  for  the  disease  was  at  last  discovered.  The  use  of 
astringents  is  generally  indispensable,  but  an  exclusive  reli- 
ance on  them  will  certainly  eventuate  in  failure ;  such  reme- 
dies also  as  are  applicable  to  an  ulcerated  condition,  would  be 
positively  injurious  under  any  other  circumstances. 

The  success,  therefore,  of  a  specific  agent  is  not  to  be  re- 
ferred to  the  power  it  possesses  over  the  disease,  like  that  of 


Essay  on  Cholera  Infantum.  325 

an  antidote  to  a  poison,  but  to  its  adaptation  to  the  morbid  con- 
dition existing  at  the  time  ;  hence  its  failure  under  a  different 
state  of  the  system  in  the  same  disease. 

The  action  of  the  known  causes  of  the  disease,  and  the 
morbid  condition  produced  by  them,  are  to  be  our  sole  guides 
in  its  management.  The  modifications  in  the  general  phe- 
nomena in  a  protracted  case,  the  predominance  of  some 
symptom  tending  to  divert  the  attention  from  the  compre- 
hensive view  necessary  always  to  take  of  the  disease,  and 
the  complications  which  arise,  will  indeed  tend  much  to 
embarrass  the  practitioner  in  his  judgment,  and  to  lead  to  a 
vacillating  mode  of  treatment.  But  while  these  untoward 
symptoms  are  duly  estimated  and  judiciously  met,  the  main 
pathological  condition  and  characteristic  development  of  the 
disease  must  always  be  kept  in  mind,  that  we  may  not  be 
induced  to  rely  too  much  upon  auxiliary  remedies. 

First  Stage. — When  the  diarrhoea  peculiar  to  teething  in- 
fants becomes  inordinately  copious  and  frequent  at  the  season 
vp'hen  cholera  infantum  prevails,  it  is  our  habit  to  regard  its 
probable  termination  in  that  disease.  K  there  are  evidences 
of  acidity  in  the  primae  vise,  it  is  best  to  neutralize  it  by  some 
fixed  alkali.  Soda  or  potass  appears  often  to  exert  a  direct 
sedative  influence  on  the  gastro-intestinal  mucous  surface,  and 
thereby  equalizes  and  lessens  the  excessive  peristaltic  motion  of 
the  bowels  ;  perhaps  this  effect  is  produced  by  simply  neu- 
tralizing the  acid  which  stimulates  the  affected  part.  The  bi- 
carbonate of  soda  combined  with  gum  arable  and  sugar, — 
about  one-twentieth  part  of  the  alkali, — makes  a  good  form 
to  administer  an  alkali  to  a  young  infant.  If  this  should  fail 
to  control  the  discharge,  the  carbonate  of  lime,  in  the  form  of 
chalk  mixture,  may  be  used.  It  sometimes  happens  that 
chalk,  like  other  alkalies,  will  form  with  the  acid  in  the  stom- 
ach a  purgative  salt,  and  the  discharges  will  be  thereby  in- 
creased. When  this  is  the  case,  or  if  the  diarrhoea  is  in  no 
degree  controlled,  the  mild  vegetable  astringents  may  be 
used.  They  may  be  freely  employed,  provided  there  exists 
no  febrile  action  nor  any  heat  of  the  abdominal  surface.    The 


326  Essay  on  Cholera  Infantum. 

root  of  the  common  blackberry,  Rubus  villosus,  or  the  root 
of  geranium  maculatum,  or  the  bark  of  the  white  oak,  Quer- 
cus  alha, — in  the  proportion  of  half  an  ounce  to  a  pint  of  milk, 
made  into  an  infusion  by  boiling,  is  a  convenient  form  for 
their  administration.  To  an  infant  of  six  months,  a  teaspoon- 
ful  may  be  given  five  or  six  times  a  day  ;  a  desert  spoonful 
to  a  child  of  two  years,  at  the  same  time  using  frictions  with 
stimulating  substances  over  the  liver.  Whenever  it  is  at- 
tempted to  arrest  any  copious  discharge  from  the  bowels,  it 
is  important  to  establish  by  such  means  some  cutaneous  re- 
vulsion by  the  use  of  a  simple  stimulating  embrocation.  At 
the  same  time  the  gums  should  be  examined,  and  if  found  to 
be  swollen,  freely  cut.  Such  is  the  mode  of  managing  too 
excessive  a  diarrhoea  from  teething. 

When  there  is  reason  for  believing  that  the  affection  will 
result  in  cholera  infantum,  the  discharge  exhibiting  less  the 
presence  of  bile,  frictions  with  mercurial  ointments  may  be 
advantageously  used,  with  or  without  the  addition  of  pow- 
dered camphor,  which  need  not  be  employed  if  any  stimula- 
ting application  to  the  skin  has  been  previously  used. 

In  mild  forms  of  cholera  infantum,  we  think  the  Hydrar- 
gyrum cum  creta  is  a  useful  medicine,  when  it  is  deemed  advi- 
sable to  resort  to  the  mercurial  management.  Objection  has 
been  made  to  it  on  account  of  its  alleged  uncertainty  of  ac- 
tion ;  this,  however,  can  only  arise  from  its  being  carelessly 
prepared,  which  may  also  be  the  case  with  any  other  com- 
pound medicine.  It  may  be  prescribed  with  advantage  in 
doses  of  five  grains  every  two  or  three  hours,  either  alone  or 
combined  with  Dover's  powder  and  carbonate  of  magnesia, 
guided  by  the  presence  of  abdominal  pain  or  of  excessive  acid. 

IJ .  Hydr.  c.  creta  3  ss. 
Pulv.  ipecac,  comp.   9j. 
Magn.  carb.  gr.  xv. 
M.  Divid.  in  pulv.  xij. 

One  of  these  powders  to  be  given  to  an  infant  once  in  four 
or  six  hours.      If  these  should  completely  arrest  the  alvine 


Essay  on  Cholera  Infantum.  327 

discharges,  aa  enema  ought  to  be  given,  and  at  least  one 
passage  secured  in  twenty-four  hours.  If  vomiting  be  pres- 
ent, the  Dover's  powder  may  be  omitted. 

Dover's  powder  is  often  useful  early  in  the  disease  ;  its 
employment  being  indicated  when  there  exists  much  fever 
and  pain  in  the  bowels.  The  addition  of  a  warm  bath  before 
prostration  has  commenced,  will  soften  the  cuticle  and  cause 
a  dilatation  of  the  cutaneous  exhalants,  and  a  diaphoresis  will, 
almost  of  necessity,  follow  its  use. 

When  the  disease  is  fully  formed,  mercury  becomes  indis- 
pensable in  its  management,  and  the  best  form  is  calomel. 
It  should  not  be  given  in  large,  purging  doses,  which  only 
irritate  the  mucous  membrane,  while  it  passes  off"  without 
producing  any  other  effect  than  increasing  the  secretion  which 
it  is  one  object  to  restrain.  From  the  twelfth  to  the  eighth 
of  a  grain  should  be  administered  every  two,  four,  or  six 
hours,  intimately  combined  with  some  inert  substance,  as  fine 
sugar.  Medicines,  it  is  well  known,  will  often  act  with  more 
efficiency  when  minutely  divided;  and  calomel  in  this  disease 
will  be  found  to  be  far  more  effective  in  producing  its  specific 
action  when  carefully  divided  by  being  rubbed  and  well  mixed 
with  the  purest  sugar.  The  combination  should  be  reduced 
to  the  finest  impalpable  state,  and  in  this  condition  made 
into  syrup  with  water.  Calomel  is  especially  useful  in  the 
first  stage  of  the  disease  ;  at  a  later  period,  when  the  evacu- 
ations have  become  excessive,  and  inflammation  and  ulcera- 
tion exist,  it  will  pass  with  the  evacuations,  and  produce  no 
effects  on  the  liver. 

The  use  of  opium  in  young  children  requires  a  great  deal 
of  cautious  judgment.  It  is  a  very  valuable  remedy  when 
judiciously  given,  and  there  is  none  so  pernicious  when  indis- 
criminately used.  At  the  commencement  of  the  disease,  it 
should  never  be  employed. 

One  of  the  chief  indications  in  the  cure  of  the  disease 
being  to  induce  an  action  on  the  liver,  and  tliereby  relieve  the 
congestion  of  that  organ  by  a  free  secretion  of  bile,  the  calo- 
mel should  be  continued  as  the  principal  means  of  relief  un- 


328  Essay  on  Cholera  Infantum. 

til  freshly  secreted  bile  appears  in  the  evacuations.  "What- 
ever be  the  other  measures  used  in  the  course  of  the  disease, 
the  liver  must  be  brought  to  its  normal  condition  by  this 
remedy.  When  a  free  circulation  of  blood  from  the  intes- 
tines is  secured,  and  the  congested  condition  of  the  remote 
branches  of  the  portal  vein  relieved,  the  disease  then  comes 
under  control. 

Such  are  the  general  measures  the  best  adapted  for  the 
cure  of  cholera  infantum,  and  are  those  which  should  be 
adopted  in  the  onset  of  the  disease,  and,  with  occasional 
modifications,  used  throughout  its  course. 

Some  alteration  may  be  required  in  the  general  course,  or 
rather  a  suspension  of  the  principal  object  maybe  necessary, 
from  the  appearance  and  persistence  of  some  violent  symp- 
tom which  may  itself  very  materially  interfere  with  the  proper 
use  of  the  appropriate  remedies,  or  become  a  source  of  severe 
and  protracted  irritation,  and  which  it  will  be  necessary  to 
counteract  by  some  special  means  adapted  to  the  nature  of 
the  existing  symptom. 

Among  the  most  obstinate  symptoms  in  the  first  stage  is 
vomiting,  and  while  it  continues  incessantly  tormenting  the 
child,  the  administration  of  the  proper  remedies  for  the 
removal  of  the  disease  is  of  little  avail ;  it  therefore  claims  a 
large  amount  of  the  physician's  attention. 

For  the  control  of  this  symptom  a  large  number  of  rem- 
edies of  the  most  opposite  nature  has  been  advised  ;  all  of 
them  at  times  successful,  and  again  not  only  useless,  but  fre- 
quently aggravating  the  symptom  for  the  removal  of  which 
they  were  given. 

The  difierent  anti-emetics  advised  in  this  disease  are,  1st. 
The  neutralizing,  such  as  the  alkalies.  2d.  The  neutralizing 
and  astringent,  as  the  alkaline  earths  in  the  form  of  lime- 
water  or  chalk  mixture.  3d.  Astringents  ;  vegetable,  as  kino  ; 
mineral,  as  the  acetate  of  lead.  4th.  Anodyne ;  as  opium. 
5th.  Stimulating ;  coff'ee,  spirits  of  turpentine,  ether,  wine, 
brandy,  etc.  6th.  Revulsives  and  rubefacients,  mustard,  red 
and  black  pepper  poultice,  camphor  as  an  embrocation,  or 


Essay  on  Cholera  Infantum.  329 

vesicatories  over  the  gastric  region,  and  stimulating  enemata ; 
and  7th.  Remedies  fulfilling  the  general  indication  for  the 
cure  of  the  disease ;  as  mercury  in  various  forms,  either  alone 
or  in  combination  with  others  for  the  accomplishment  of  the 
same  end ;  as  calomel  or  blue  pill  with  Dover's  powder  or 
prepared  chalk.  All  of  these  have  been  recommended  from 
experience  in  their  use,  but  it  is  plain  that  they  could  only 
be  successful  from  different  conditions  of  the  stomach  at  the 
time  of  their  employment,  and  are  not  applicable  to  other 
cases  where  similar  conditions  do  not  exist. 

Although  vomiting,  particularly  when  the  disease  is  fully 
formed  in  the  first  stage,  may  be  regarded  as  essential  to  the 
disease,  yet  it  is  evident,  from  the  nature  of  the  different  rem- 
edies, that  some  difference  must  exist  in  the  pathological  con- 
dition of  the  organ  which  is  its  seat,  and  which  can  in  general 
be  ascertained  by  carefully  watching  the  symptoms  attending, 
and  noting  the  state  of  the  whole  system,  whether  one  of 
excitement  or  exhaustion. 

At  the  beginning  of  the  disease  there  appears  always  to 
exist  acidity,  and  we  invariably  begin  with  some  alkali ;  lime- 
water  combined  with  milk  rarely  fails  to  arrest  the  vomiting 
at  the  expiration  of  two  hours,  when  given  every  half-hour  in 
the  dose  of  one  teaspoonful  of  the  mixture,  consisting  of 
equal  quantities  of  the  two  articles.  Although  at  times  read- 
ily arrested,  it  will  recur,  and  will  probably  be  arrested  the 
second  and  third  time.  If  the  disease  progresses  it  cannot  be 
controlled  by  this  simple  means,  other  and  more  powerful 
measures  will  be  required.  Applications  of  a  stimulating 
kind  can  then  be  used  to  the  surface  covering  the  stomach, 
but  blistering  should  never  be  employed.  Blisters  appear  to 
be  always  positively  prostrating  to  young  infants,  particularly 
when  applied  to  this  part  of  the  body.  Revulsives  by  stimu. 
lating  enemata  will  transfer  the  irritation  ;  and  if  dysenteric 
symptoms  appear,  vomiting  usually  ceases ;  it  rarely  occurs 
when  these  symptoms  arise  early  in  the  disease.  Of  the  two, 
irritation  in  the  rectum  isto  be  ch  osen.     Mildly  stimulating 


330  Essay  on  Cholera  Infantum. 

enemata,  are  important  remedies  in  severe  vomiting  wliicli 
resists  other  measures. 

But  it  often  happens  that  great  exhaustion  follows  a  severe 
and  protracted  vomiting,  and  stimulants  are  indicated  and 
often  receive  the  appellation  of  specifics,  when  it  is  simply 
the  condition  of  the  system  that  makes  them  efficacious,  and 
whatever  is  the  last  employed  is  usually  regarded  as  possess- 
ing anti-emetic  properties.  Strong  coffee,  or  brandy,  is  among 
these,  and  under  the  circumstances  just  mentioned,  highly 
useful  in  rallying  the  system  and  relieving  the  stomach  by 
the  general  stimulation  of  the  circulation. 

Thus,  by  endeavoring  to  ascertain  the  actual  condition,  it 
may  be  in  our  power  to  control  and  manage  to  some  extent 
this  obstinate  difficulty  to  the  general  management  of  the 
disease. 

Instead  of  vomiting,  tenesmus  is  at  times  the  most  distress- 
ing symptom,  and  is  exceedingly  wearing  to  the  young  infant. 
Irritation  about  the  rectum  is  almost  sure  to  relieve  vomiting, 
and  may  therefore  be  but  little  interfered  with  ;  but  when  it 
passes  into  severe  tenesmus,  mild  anodyne  enemata  should  be 
used.  They  ought  to  be  employed  with  great  caution.  The  rule 
in  the  adult  is,  to  give  three  times  the  amount  of  the  tincture  of 
opium  by  injection  as  it  is  usual  to  administer  by  the  mouth. 
This  rule  is  inadmissible  when  young  children  are  treated. 
Children  are  peculiarly  susceptible  to  the  action  of  opium, 
although  a  most  decided  advantage  often  follows  its  use  in 
the  characteristically  irritable  condition  of  the  system  at  this 
period  of  life  ;  yet,  from  the  great  rapidity  of  absorption  at 
that  time,  a  small  quantity  cannot  be  given  without  incurring 
some  risk.  Let  it  be  first  given  in  an  enema  in  the  quan- 
tity which  would  be  given  by  the  mouth,  and  repeated  if  it 
should  be  returned,  rather  than  increased  in  quantity.  After 
a  few  trials,  the  quantity  may  be  cautiously  increased. 

During  the  continuance  of  the  disease,  although  free 
serous  evacuations  continue,  the  ordinary  faeces  are  apt  to  be 
retained.  This  may  be  suspected  when  the  abdomen  becomes 
tumid,  and  the  alvine  evacuations  have  undergone  no  altera- 


Essay  on  Cholera  Infantum.  331 

tions.  If  the  mercurial  preparations  have  failed  to  procure 
an  evacuation  of  fseces,  a  laxative  consisting  of  magnesia  and 
rhubarb,  will  be  proper  to  remove  the  highly  irritating  con- 
tents of  the  bowels.  There  is  often  acid  existing  in  the  sto- 
mach and  bowels  in  this  disease  ;  for  from  the  absence  of  bile 
no  neutralization  occurs,  and  dissections  have  exhibited  the 
presence  of  a  frothy,  acid  matter  in  different  parts  of  the  bow- 
els. The  combination,  therefore,  of  some  alkaline  remedy  will 
be  called  for  by  this  probable  condition.  When  there  is  no 
fever  present,  the  aromatic  syrup  of  rhubarb  and  magnesia 
will  be  found  a  useful  prescription.  The  object  being  simply 
to  relieve  the  bowels  of  the  load  of  irritating  fseces,  such 
measures  are  indicated  as  will  at  the  same  time  tend  to  pro- 
duce a  lessened  flow  of  the  serous  discharge  from  the  exha- 
lent  vessels  of  the  mucous  membrane. 

As  to  the  employment  of  astringents  a  great  deal  of  caution 
is  to  be  used,  neither  rejecting  them,  nor  using  indiscrimi- 
nately such  measures  as  will  at  once  arrest  the  most  promi- 
nent and  exhausting  symptom  of  the  disease.  Although 
astringent  remedies  are  not  to  be  regarded  as  the  principal 
mode  of  cure,  yet  when  the  child  appears  to  be  rapidly  sink- 
ing from  excessive  exhaustion  produced  by  large  serous  evac- 
uations, it  will  be  advisable  to  employ  some  of  those  already 
mentioned,  or  others  of  a  more  powerful  efficacy. 

Whenever  it  has  been  deemed  advisable  to  resort  to  the 
use  of  astringents,  we  have  been  in  the  habit  of  using  them 
as  auxiliary  remedies,  and.  that  their  action  may  not  be  inter- 
fered with,  to  suspend  for  a  short  time  the  mercurial  course. 
Tannin,  either  pure  or  as  it  occurs  in  kino  and  catechu,  will 
often  temporarily  arrest  the  discharges.  One  of  the  most 
efficacious  astringents  is  the  acetate  of  lead,  combined  with 
Dover's  powder  in  the  proportion  of  the  third  of  a  grain  of 
the  former  to  the  twelfth  of  a  grain  of  the  latter,  to  a  child 
of  fifteen  months  once  every  two  hours.  When  the  secretion 
of  bile  is  established,  there  is  nothing  so  well  adapted  to 
complete  the  cure  as  this  combination.  When  using  the 
stronger  vegetable  astringents,  as  kino  or  tannin,  it  will  be 


332  Essay  on  Cholera  Infantum. 

necessary  to  stop  the  animal  gelatine  which  may  have  been 
used  as  diet ;  or  it  will  form  with  them  an  insoluble  compound, 
and  add  to  the  existing  disease  the  irritation  of  a  foreign,  indi- 
gestible article. 

Second  Stage. — The  treatment  of  what  we  have  called 
the  second  stage  of  the  disease,  is  that  which  will  be  best 
adapted  to  remove  the  inflammation  and  ulceration  of  the 
affected  parts.  If  the  inflammatory  period  is  early  in  its 
invasion,  and  appears  almost  simultaneous  with  the  appear- 
ance of  the  disease,  a  leech  to  the  verge  of  the  anus  will  be 
advisable.  If  this  should  not  afford  relief,  one  or  two  may 
be  applied  over  the  region  of  the  liver,  or  dry  cupping  may 
be  used  to  the  same  part,  according  to  the  ability  of  the  child 
to  bear  the  depleting  process.  It  is,  however,  exceedingly 
rare  that  the  loss  of  blood  is  required, — the  inflammatory  or 
congestive  stage  appearing  usually  after  a  large  loss  of  fluids 
has  debilitated  the  little  patient,  clearly  forbidding  the  use  of 
sanguinary  depletion.  When  these  symptoms  appear  after 
some  days,  the  most  that  the  child  can  bear  is  dry  cupping 
in  different  parts  of  the  abdomen,  followed  by  fomentations 
of  warm  water.  It  is  well  known  to  practical  men  that  in- 
stances constantly  occur  where  there  exists  local  inflamma- 
tion, and  where  it  would  be  exceedingly  rash  to  abstract 
blood ;  this  is  especially  the  case  in  the  disease  under  consid- 
eration. 

In  that  state  of  the  system  which  exhibits  this  affection 
with  inflammatory  action  and  fever,  the  mercury  which  is 
given  may  very  advantageously  be  combined  with  Dover's 
powder.  There  is  not  much  danger  of  exciting  vomiting  by 
its  use  ;  for,  as  has  already  been  remarked,  when  the  disease  is 
exerting  its  force  on  the  intestines  with  an  inflammation  of 
these  parts,  there  is  but  little  disturbance  of  the  stomach. 
Half  a  grain  of  Dover's  powder,  with  the  sixth  of  a  grain  of 
calomel,  may  be  given  every  four  or  five  hours.  We  have 
thought  that  there  is  less  irritation  to  the  mucous  membrane 
in  this  stage  of  the  disease,  where  the  blue  pill  is  substituted 
for  the  calomel. 


Essay  on  Cholera  Infantum,  333 

It  is  in  this  stage  of  development  especially,  although 
useful  throughout  the  disease,  that  we  have  found  gelatine, 
either  alone  or  combined  with  milk,  highly  beneficial  in  its 
management.  It  is  so  soluble  as  to  be  easily  and  entirely 
absorbed,  and  if  it  supply  but  partial  nourishment  to  the 
wasting  body,  or  if  it  be  altogether  what  is  denominated 
respiratory  food,  and  indirectly  prevents  the  oxidation  of  the 
tissues,  yet  it  is  especially  an  unirritating  substance  to  the 
tender  mucous  surface,  difiering  altogether,  in  this  respect, 
from  any  of  the  vegetable  mucilages  or  jellies,  which,  for  the 
most  part  are  undissolved. 

Combined  with  this  inflammatory  condition  is  a  greater  or 
less  ulceration,  exhibited  in  the  discharges  already  referred 
to,  when  speaking  of  the  symptoms.  It  is  in  this  state  that 
the  nitrate  of  silver  is  beneficial,  and  it  is  probable  that  it  is 
under  the  same  circumstances  that  sulphuric  acid  or  creasote 
has  been  employed  with  advantage.  The  nitrate  of  silver 
appears  to  be  well  adapted  to  the  ulceration  of  the  diseased 
parts,  and  when  judiciously  used,  is  a  very  soothing  and  effi- 
cacious remedy  to  the  inflamed  j^arts.  It  may  be  given  in 
the  quantity  of  one-twelfth  of  a  grain,  with  about  one  drop  of 
the  tincture  of  opium,  three  times  a  day. 

Third  Stage. — This  is  the  period  of  complication.  When 
the  cerebral  symptoms,  such  as  congestion  and  stupor,  appear, 
very  little  if  any  treatment  is  of  any  use.  We  have  often 
resorted  to  the  various  modes  of  combating  congestion  of 
this  organ  at  this  period,  and  have  as  often  failed  in  obtaining 
any  relief  We  regard,  therefore,  the  symptoms  marking  this 
stage  as  preceding  a  fatal  termination. 

The  Chronic  form. — When  the  disease  is  greatly  protract- 
ed, it  becomes  mixed  in  its  character,  and  often  attended  with 
great  prostration.  In  this  chronic  condition,  the  continuance 
of  an  astringent  course,  with  a  judicious  use  of  tonics,  becomes 
necessary.  A  close  attention  to  the  symptoms  will  be  partic- 
ularly necessary  in  this  form,  which  partakes  of  the  mixed 
character  of  a  chronic  diarrhoea,  and  may  properly  be  denom- 
inated a  sequel  of  cholera  infantum 
24 


334  Essay  on  Cholera  Infantum. 

This  chronic  condition  will  often  continue  without  any 
very  decided  symptom  of  inflammatory  action,  at  least  to 
such  a  degree  as  to  require  direct  anti-phlogistic  remedies : 
an  inflammatory  irritation  will  exist,  keeping  up  the  morbid 
symptoms,  and  wasting  the  strength  of  the  child  by  the  con- 
stant discharge  from  the  bowels.  Under  these  circumstances, 
it  will  be  necessary  to  resort  to  astringents,  cautiously  used, 
or  to  some  of  the  stimulants  which  possess  astringent  proper- 
ties, and  which  appear  to  exert  some  peculiar  power  on  the 
mucous  membrane.  Nitric  acid  is  a  medicine  of  this  kind, 
and  in  tedious  cases  will  often  act  in  a  favorable  manner  by 
allaying  the  morbid  action  of  the  mucous  membrane.  Six 
drops  of  this  acid,  with  six  drops  of  the  tincture  of  opium,  may 
be  diluted  with  an  ounce  and  a  half  of  water,  of  which  a  tea- 
spoonful  may  be  given  once  in  three  or  four  hours.  When 
there  is  excessive  relaxation  an  infusion  of  simarouba  bark 
may  be  substituted  for  the  water,  and  the  mixture  rendered 
slightly  stimulating  by  the  addition  of  the  syrup  of  ginger  or 
of  oil  of  cinnamon,  or  a  drop  of  the  oil  of  cloves,  rubbed  up 
with  sugar,  and  added  to  the  mixture.  In  similar  cases  of 
atony,  the  sulphate  of  iron  lias  been  found  useful  in  doses  of 
one  quarter  of  a  grain  three  or  four  times  a  day.  The  tartrate 
of  iron  is  also  useful  for  the  same  object,  that  of  imparting 
tone  and  astringing  the  parts.  Ten  grains  may  be  dissolved 
in  half  an  ounce  of  water,  with  the  addition  of  one  of  the 
essential  oils  just  mentioned  ;  of  this  mixture,  twenty  drops 
may  be  given  four  times  a  day. 

Throughout  the  whole  of  the  chronic  or  secondary  disease, 
debility  is  a  prominent  symptom ;  and  while  the  discharges 
are  restrained  by  appropriate  remedies,  whatever  can  impart 
tone  by  a  proper  stimulating  influence  should  from  time  to 
time  be  used.  One  of  the  best  we  know  of,  is  the  compound 
tincture  of  cinchona,  known  as  Huxham's  tincture;  the  com- 
bination of  the  stimulating  ingredients  makes  it  peculiarly 
adapted  to  the  restoration  of  the  lost  tone  of  the  stomacli  and 
intestines.  Tincture  of  kino,  tannic  acid,  and  other  astring- 
ents may  also  be  resorted  to,  with  the  addition  of  one  of  the 


Essay  on  Cholera  Infantum.  335 

essential  oils,  as  some  stimulant  will  be,  in  most  instances,  re- 
quired in  the  greatly  relaxed  and  prostrated  condition  of  the 
patient;  the  astringents  scarcely  acting  of  themselves.  When 
alcoholic  stimulants  are  needed,  we  always  prefer  brandy  to 
wine,  and  always  commence  with  brandy  and  water  ;  if  this 
agrees  well  with  the  child,  we  then  combine  the  brandy  with 
isinglass  jelly,  and  if  no  untoward  symptom  arises  from  its 
use,  change  it  for  milk  punch,  as  supplying  the  most  nourish- 
ment. Often  have  we  seen  a  child  rally  with  surprising 
promptness  when  a  little  brandy  has  been  given.  The  symp- 
toms are  so  varied  and  so  combined,  that  a  great  variety  of 
medicines  has  been  used  to  meet  the  different  indications  ; 
most  of  them,  however,  of  a  tonic  or  stimulating  nature,  so 
modified  by  suitable  combinations  as  to  meet  the  peculiar  cir- 
cumstances as  they  arise.  Otber  stimulants  are  of  a  specific 
character,  and  act  directly  on  the  mucous  membrane ;  of  this 
kind  is  the  balsam  of  copaiba,  which  may  be  given  in  doses  of 
three  or  four  drops,  twice  a  day.  In  this  class,  also,  is  nitrate 
of  silver,  already  mentioned. 

The  instinctive  desire  for  animal  food  at  this  time,  is 
singularly  craving,  and  may  safely  be  indulged.  Butter,  fat 
salted  meats,  fresh  meats  abounding  in  juices,  are  eagerly 
seized  by  the  child,  and  are,  perhaps,  the  best  stiinuhmts  that 
can  be  given — far  more  efiicacious  than  those  (  f  a  therapeu- 
tic nature. 

In  the  management  of  this  disease,  our  efforts  must  be 
chiefly  exerted  in  its  incipiency,  and  during  the  stages  when 
it  still  exhibits  as  its  most  marked  phenomenon,  the  condition 
resulting  from  an  excessive  and  morbid  development  of  the 
parts  which  constitute  and  characterize  the  affection. 

The  transition  from  a  healthy  state  in  a  young  child  to 
that  of  disease,  is  rapid,  both  from  high  nei-vous  sensibility, 
and  from  the  quick  interstitial  growth  of  parts.  Tiie  effects 
of  the  exciting  causes  show  themselves  promptly  ;  and  early 
in  the  disease  are  simple  in  their  manifestation,  decided  in 
their  character,  and  with  little  or  no  complication.  It  there- 
fore becomes  a  task  promising  more  than  ordinary  results,  to 


336  Essay  on  Cholera  Infantum. 

examine  well  and  thorougHj  into  the  nature  of  the  exciting 
agents,  and  their  action  on  the  economy  of  the  system ;  to 
learn,  if  possible,  in  what  manner  the  diseased  development 
is  connected  with  the  ordinary  development  of  the  affected 
parts. 

Regarding  the  process  of  growth  as  a  great  predisposing 
cause  of  disease  among  children,  we  have  endeavored  to  trace 
the  diseased  condition  in  cholera  infantum  from  its  com- 
mencement as  a  simple  natural  development,  and  to  connect 
this  development  with  the  well-known  causes  which  are  ac- 
tive in  the  production  of  the  morbid  changes  in  the  parts 
affected  in  the  disease,  and  have  thereby  been  enabled  to 
present  the  subject  in  a  strictly  practical  aspect.  The  pre- 
ventive and  hygienic  measures  for  relief,  so  abundantly 
proved  by  experience,  have  their  full  explanation  in  the  phi- 
losophical consideration  of  the  subject ;  while  the  same  inves- 
tigation bears  directly  to  the  establishment  of  the  principles 
on  which  the  therapeutic  management  is  founded. 


APPE  NDIX. 


A. 

It  is  remarkable  that  Dr.  Cleghorn  should  for  the  first  time  have  made 
the  discovery  referred  to,  in  Minorca,  and  also  that  on  his  return  to  Great 
Britain  he  should  not  have  recognized  the  disease  of  which  he  speaks,  if  it 
was  a  peculiar  affection  in  his  country.  His  talent  for  observation  appears 
to  have  been  unequaled.  Dr.  Fothergill,  in  a  letter  to  Dr.  Cuming,  August 
14th,  1742,  awards  the  following  praises  to  him :  "  Thou  wilt,  no  doubt, 
admire  the  industry  of  our  friend  Ckghorn,  who  situated  in  a  corner  of  the 
world,  has  made  greater  progress  than  any  of  us  who  even  do  not  want  the 
proper  aids  of  study.  Let  us,  therefore,  stimulate  one  another,  that  we 
may  follow  his  footsteps,  and  become  the  worthy  friends  of  so  great  a  man." 
— Mem.  of  John  Fothergill,  M.  2).,  ly  John  Coakley  LetUom,  p.  104. 

Dr.  Cleghorn's  observations  in  Minorca  embraced  a  period  of  seven 
years.  In  three  of  these  he  mentions  the  existence  of  "  cholera  morbus " 
among  children,  in  connection  with  several  other  diseases.  In  the  other 
four  years  no  mention  of  such  affection  occurs.  The  following  is  his  only 
account : 

1744.  "  From  the  end  of  June,  the  young  children  (who  constantly 
suffer  first  by  excessive  heat  and  cold)  are  attacked  with  vomiting,  purging, 
and  periodical  fever." 

1747.  'About  the  end  of  the  month  [June],  the  cholera  morbus  carried 
off"  many  children." 

1748.  "  The  ensuing  summer  proved  very  unhealthy  to  children,  many 
of  them  dying  of  cholera  morbus." 

It  would  appear  from  this  that  the  disease  was  not  uniform  as  to  the 
time  of  its  invasion ;  and  the  remark  in  the  last  mentioned  year,  seems 
to  convey  the  idea  that  it  was  an  unusual  season  for  sickness  among  chil- 
dren. 

The  following  extract  is  from  the  remarks  of  Dr.  G.  R.  B.  Horner,  of 


338 


Ajypendix. 


the  F.  S.  Navy,  on  the  diseases  of  Minorca'raade  from  observations  during 
the  period  betvi'cen  1831  and  1838,  inclusive:  "Dysenteric  and  other  dis- 
orders of  the  alimentary  canal  prevail,  but  I  am  not  aware  that  the  former 
does  to  such  a  degree  as  to  be  called  epidemic  ;  and  in  this  respect  the  cli- 
mate seems  to  have  undergone  a  material  change  since  Cleghorn  lived  in 
Minorca." 


B. 


The  following  table,  taken  from  a  paper  by  Drs.  Nilcs  and  Russ,  in  the  New 
York  Medical  and  Physical  Journal,  v.  6,  gives  the  number  of  deaths  for 
eleven  years  of  several  prominent  diseases,  showing  the  influence  of  temper- 
ature on  mortality  in  that  city. 


Diseases. 


Consumption 

Acute  Diseases  of  Lungs 

Fevers, 

Dropsies, 

Cholera  Infantum, 

Dysentery 

Croup 

Tabes  Mesenterica 

Gastro-enteritis, 

Hooping  Cough, 

Apoplexy, 

Measles, 

Intenoperanoe 

Disease  of  Liver,. . . . . . 

Palsv, 


660 

200 

178 

244 

2 

22 

137 

68 

48 

53 

49 

48 

49 

48 

42 


659 

644 

664 

616 

292 

254 

250|210 

137 

158 

186 

211 

257 

241 

245 

254 

2 

2 

1 

5 

14 

29 

7 

16 

106 

122 

106 

91 

66 

85 

95 

97 

54 

56 

60 

60 

66 

42 

33 

37 

69 

56 

47 

57 

42 

46 

45 

32 

32 

33 

31 

49 

46 

34 

35 

34 

42 

44 

3l| 

28 

a 

3 

§ 

3 
< 

a 

■2 

D. 

m 

z 

o 

o 

u 

o 

S 

§ 

25 

i 

i 

0 

519 

591 

663 

579 

588 

645  656 

114 

117 

105 

92 

141 

152  172 

245 

262 

374 

497 

441 

305  211 

259 

241 

272 

308 

269 

259  245 

32 

246 

527 

288 

108 

14  18 

28 

233 

489 

378 

203 

79,  36 

66 

69 

67 

84 

140 

139  122 

69 

80 

126 

139 

135 

89  84 

76 

121 

97 

94 

69 

67  39 

31 

73 

105 

105 

71 

66  49 

45 

109 

59 

45 

59 

65|  67 

49 

65 

77 

45 

34 

24'  45 

47 

46 

43 

44 

47 

63'  47 

39 

57 

44 

36 

64 

41  50 

28 

31 

38 

25 

41 

39 

44| 

7466 

2069 

3205 

3044 

1245 

1544 

1239 

1115 

861 

721 

697 

552 

531 

528 

428 


c. 


The  spring  and  summer  of  1816  were  remarkably  cold.  Various  dis- 
cussions appeared  in  the  newspapers  and  philosophical  periodicals,  as  to  the 
cause.  It  was  attributed  to  spots  in  the  sun  ;  to  numerous  ice-islands  on 
the  coast;  and  to  the  existence  of  a  vapor  which  filled  the  atmosphere, 
"  equally  dense  and  yet  diaphonous,  all  over  the  horizon,  that  existed  at  times 
in  the  atmosphere."  This  cold  existed  till  the  middle  of  June,  with  repeated 
frosts,  which  injured  many  wheat,  rye,  and  corn  fields  in  this  and  the  neigh- 
boring States.    In  the  latter  part  of  June  the  temperature  arose  to  87°,  but 


Appendix.  339 

again  descended  and  continued  to  the  15th  of  July  from  15°  to  20°  below 
summer  temperature.* 

In  the  year  1816,  there  was  frost  on  Long  Island  in  every  month  of  the 
year,  and  the  corn  was  killed  almost  universally  by  the  5th  of  September.! 

Numerous  reports  were  brought  in  by  vessels  arriving  at  New  York,  of 
immense  ice-islands  in  the  Atlantic,  near  the  coast.  Up  to  the  1st  of  July 
thirteen  different  accounts  of  these  were  published  in  the  newspapers. 

The  temperature  of  the  city  of  New  York  when  compared  with  that  of 
London  is  very  remarkable.  In  the  former  city  the  mean  of  the  summer 
is  75°  :  of  the  latter  60° .  The  highest  range  in  London  is  82° ,  in  New 
York  97° .  It  is  said  by  some  that  the  disease  exists  in  London ;  if  so,  it  is 
certainly  to  a  very  limited  extent,  if,  as  we  have  seen,  excessive  heat  is  essen- 
tial to  its  development 

D. 

The  dreadful  pestilence  that  raged  in  Athens  appears  to  have  been  of 
malarial  origin,  and  to  have  affected  all  living  creatures  at  a  distance  from  hu- 
man habitations.  The  sheep  died  in  solitude.  Lucretius  observes,  that 
even  the  birds  in  the  woods,  which  they  never  deserted,  and  the  beasts 
near  the  streams  of  water,  and  in  fields  and  pastures,  died  in  excessive 
numbers, — 

"Nee  tamen  omnino  temere  illis  solibus  uUa 
Conparebat  avis,  neque  Doxia  secla  ferarum 
Exibant  sylvis :  languebant  pleraque  morbo, 
Et  moriebantur."t 

"  Hsec  igitur  subito  clades  nova,  pestilitasque, 
Aut  in  aquas  cadit,  aut  fruges  presidit  in  ipsas, 
Aut  alios  hominum  pastus,  pecudumque  obatus; 
Aut  etiam  subspensa  manet  vis  aere  in  ipso: 
Et,  quom  spirates  mixtas  bine  ducimus  auras, 
Ilia  quoque  in  corpus  pariter  sobere  necesse  est. 
Consimili  ratione  venitbubus  quoque  esepe 
Pestilitas ;    etiam  pigris  balantibis  8egros."§ 

In  the  year  of  Rome  290  a  severe  pestilential  disease  spread  throughout 
the  city  and  country,  affecting  equally  men  and  beasts.  "  Grave  tempus 
et  forte  annus  pestilens  erat  urbi,  agrisque,  nee  hominibus  magis,  quam 

*  Med.  Repository,  3  vol.  New  Series. 

t  History  of  Long  Island  by  Henry  F.  Thompson. 

\  Lucretius,  Lib.  vi.  1217. 

§  Ihid,  Lib.  vi.  1125. 


34:0  Appendix. 

pecori ;  et  auxere  vim  morbi  tenore  populationis,  pecoribus  agrestibusque, 
in  urbem  acceptis.''* 

Lancisi  mentions  that  in  the  Roman  States  the  epizootics  are  very  prev- 
alent, and  exhibit  much  the  same  symptoms  as  malarious  diseases  do  in  the 
man.  McCulloch  refers  to  their  existence  in  Hungary,  St.  Domingo, 
Guadaloupe,  France,  and  Italy,  to  a  great  extent,  in  1711,  1745,  1772,  1785 
and  1795,  and  in  other  countries,  among  all  kinds  of  cattle,  flocks  of  sheep, 
and  wild  beasts  and  birds, — all  from  paludal  miasms. 

Barron  Larrey,  in  his  surgical  memoirs,  speaks  of  the  havoc  made  on  the 
cows  and  oxen  during  Napoleon's  campaign  in  Italy  from  the  effects  of  ma- 
laria, thus:  "  Les  reseignmens  que  je  recueillie  aupres  des  habitans,  les 
recherches  aux  quelles  je  me  livrai,  m'assurerent  que  I'epizootie  reconnaissait, 
pour  principales  causes,  la  mauvaise  qualite  des  fourages,  I'etat  marecageux 
des  paturages,  la  chaleur  excessive  et  prolongee  qui  avait  succedee  tout-a- 
coup  a  un  printemps  pluvieux  et  orageux.  Les  pluies  d'orage  avaient  con- 
siderablement  grossi  les  torrens,  les  rivieres,  et  en  avaient  cause  le  deborde- 
ment :  une  partie  de  ces  eaux,  apres  avoir  nui  aux  recoltes,  etait  restee  en 
stagnation  dans  les  lieux  bas  et  enfonces ;  ce  qui  avoit  forme  autant  de 
marecages."t 

"  Animals  which  feed  in  marshes  where  these  fevers  prevail,  are  found 
to  have  diseased  livers.  In  the  town  of  "Wolcott,  Seneca  county,  where 
marshes  and  low  lands  abound,  the  hogs,  when  killed,  are  generally  found 
with  corroded  livers."^ 


E. 

The  following  remarks  are  from  the  report  of  the  committee  on  the  sub- 
ject of  the  "  Agency  of  the  refrigeration  produced  by  upward  radiation  of 
heat,  as  an  exciting  cause  of  disease."  It  also  gives  the  amount  of  existing 
knowledge  as  to  the  immediate  cause  of  the  invasion  of  miasmatic  diseases. 
"  Most  authors  who  have  treated  upon  atmospheric  influences  to  which  per- 
sons are  exposed,  have  confined  their  attention  to  the  conditions  of  excessive 
moisture  or  malarious  effluvia,  the  products  of  putrefaction.  During  the  ex- 
istence of  such  circumstances,  according  to  our  view,  let  any  one  be  sub- 
jected to  the  chilling  influences  exerted  through  upward  radiation  from  ex- 
posure during  the  night  to  the  clear  open  sky,  and  fever  of  the  specific 
character  prevalent  will  be  the  result ;  or,  in  the  absence  of  such  epidemic 

*  Tit.  Liv.  lib.  3,  c.  6. 
I  Mem  de  Chir.  Militaire,  tome  1,  p.  165. 

X  Inaugural  Dissertation  on  the  Lake  Fevers  and  other  Diseases   of  the 
Genesee  country  in  the  State  of  New  York.     Edward  G.  Ludlow,  1823. 


Appendix.  341 

agents,  diarrhoea,  rheumatism,  or  other  inflammatory  affections  may  occur 
instead." 

"In  cities  there  is  a  compensation  for  the  loss  of  beat  through  radiation. 
The  walls  and  pavements  absorb  more  heat  by  day,  than  they  can  possibly 
throw  off  at  night.  Hence  the  remaining  heat  prevents  the  detrimental  ef- 
fects of  refrigeration  from  that  partial  radiation  which  alone  can  take  place 
in  cities.  Persons  can,  therefore,  go  about  at  night  in  cities  with  almost 
as  much  impunity  as  by  day,  and  this  during  the  prevalence  of  epidemic 
influences  which  intrude  themselves  no  farther  than  the  precincts." 


F. 

Two  long  articles  are  in  the  Evening  Post  of  September  20th  and  October 
1st,  1828,  on  the  subject  of  the  origin  and  extreme  virulence  of  the  miasm. 
The  Long  Island  Star  of  the  18th  of  September  of  the  same  year,  has  the 
following  editorial : 

"  Malaria. — The  sickness  which  now  prevails  on  Long  Island,  and 
which  suddenly  attacks  whole  families,  is  considered  by  some  to  be  the 
malaria  so  well  known  in  Europe,  and  which  arises  from  heat,  moisture,  and 
the  decay  of  vegetables.  Its  effect  in  some  places  has  been  dreadful  indeed, 
and  we  trust  will  call  forth  the  investigation  of  gentlemen  of  medical  talent." 

The  following  are  from  the  New  York  Enquirer  of  the  same  year  :  Sep- 
tember 2d — "  In  several  parts  sickness  has  made  its  appearance  in  the  shape 
of  fevers,  &c.  Long  Island  particularly  groans  heavily,  notwithstanding  its 
proximity  to  the  sea."  October  3d — "It  is  very  sickly  on  Staten  Island, 
many  families  suffering  for  want  of  medical  aid." 

Journal  of  Commerce,  October  3d,  1828  :— "  The  epidemic  fever,  both 
intermittent  and  remittent,  which  has  been  mentioned  as  prevailing  in  some 
parts  of  Long  Island,  still  continues,  and  has  increased  of  late,  particularly 
in  the  vicinity  of  Newtown,  Bush  wick,  &c.  It  is  probable  that  it  will  con- 
tinue unabated  until  we  are  favored  with  frost,  that  sovereign  antidote  to  au- 
tumnal levers.  This  city  has  enjoyed  unusual  health,  and  many  fam- 
ilies that  moved  into  the  country  from  fear  of  sickness  precipitately  re- 
turned. Our  bills  of  mortality  show  that  the  number  of  deaths  has  fallen 
below  the  average  of  years.  It  is  a  little  remarkable,  too,  that  all  the 
cases  of  bilious  fever  of  obstinate  character  which  have  occurred  in  New 
York,  have  been  contracted  in  Long  Island  and  New  Jersey  or  neighbor- 
ing country." 


342 


Appendix. 


In  that  year,  it  is  stated  in  the  '■'■  Statistical  report  on  tJie  sicTcness  and  mor- 
tality in  the  army  of  the  United  States"  that  malarial  diseases  prevailed  very 
extensively  around  Fort  Hamilton,  L.  I.  "The  laborers  employed  in  1828 
in  the  erection  of  this  post — a  locality  which  had  been  previously  exempt 
from  the  effects  of  malaria — suffered  greatly  from  intermittent  and  remit- 
tent fevers.  The  elevated  coasts  of  Long  Island  in  the  vicinity  of  the  Nar- 
rows, where  a  case  of  intermittent  fever  was  unknown  in  the  memory  of  the 
oldest  inhabitant,  became  so  rife  with  intermittent  and  remittent  fevers  as 
to  drive  the  inhabitants  from  their  possessions. 


G. 


By  this  table,  made  from  the  City  Inspector's  report,  it  will  be  seen  what 
little  influence  was  exerted  on  the  mortality  by  cholera  infantum  by  mala- 
rious epidemic  of  1828,  in  the  vicinity  of  New  York.  No  remarkable  sick- 
ness existed  in  any  of  the  other  years. 


WHOLE    NO.    OF   DEATHS. 


1825 

1826, 

1827 

1828 

1829 

1830 

1850 

1851 

1852 

1853 

1854 


DEATHS  FROM  CHOLERA.  INFANTUM. 


5,018 

151 

4,973 

222 

5,118 

238 

5,181 

161 

5,094 

119 

5,537 

168 

16,978 

713 

22,024 

721 

21,601 

915 

22,702 

922 

28,568 

1,525 

1  in  33 
22 
22 
31 
42 
32 
23 
30 
23 
24 
19 


H. 


Extract  from  the  report  of  the  committee  on  the  epidemics  of  Tennessee 
and  Kentucky. 

*'  Cholera  Infantvm. — This  is  a  disease  which  has  almost  disappeared 
from  considerable  portions  of  this  district,  whilst  it  continues  to  prevail  in 
other  portions  as  much  as  ever.  Notwithstanding  much  attention  has  been 
bestowed  upon  this  disease  in  the  United  States,  and  especially  in  the  west 
and  southwest,  it  is  doubtful  whether  the  diagnosis  is  not  even  yet  in- 
volved in  some  obscurity;  whether  in  fact,  other  diseases  are  not  frequently 
called  hy  that  name" 


Appendix.  343 

"Cholera  infantum  usually  begins  early  in  the  season,  in  May,  for  exam- 
ple, and  frequently  continues  until  October."* 

In  the  table  already  given  in  this  Appendix,  the  entire  number  for  eleven 
years  reported  for  the  month  of  May,  is  five,  out  of  twelve  hundred  and  forty- 
five  for  the  whole  period. 


I. 

Extract  from  Emerson's  Medical  Statistics  of  Philadelphia : — "  Bowel 
complaints,  as  the  most  destructive,  stand  first  in  this  order  (the  mortality 
among  children) ;  of  these  about  two-thirds  are  under  the  general  designation 
of  Cholera,  nearly  all  of  which  were  doubtless  entitled  to  the  specific  appel- 
lation of  cholera  infantum,  a  disease  almost  peculiar  to  the  United  States, 
in  many  parts  of  which  it  exists  endemically  under  the  name  of  summer 
complaint.  Of  three  thousand  eight  hundred  and  twelve,  the  whole  amount 
of  deaths  reported  from  cholera,  adults  and  children  inclusive,  three  thou- 
sand six  hundred  and  thirty-nine  were  under  the  age  of  puberty,  and  three 
thousand  five  hundred  and  seventy-six  under  the  fifth  year,  viz.  :  two  thou- 
sand one  hundred  and  twenty-two  under  the  first  year,  one  thousand  one 
hundred  and  eighty-six  between  the  first  and  second  years,  and  only  two 
hundred  and  sixty-eight  over  the  second  year.  As  this  affection  seldom  at- 
tacks them  beyond  the  fifth  year ;  the  balance  of  two  hundred  and  thirty- 
six,  between  the  amount  of  that  period  and  the  total  of  all  ages,  may  be 
counted  as  cholera  morhus.^ 


The  following,  from  "  Essays  Medical  and  Moral,"  etc.  v.  2,  by  Thomas 
Beddoes,  M.  D.,  will  sufficiently  prove  the  fact  that  heat  alone  will  produce 
affections  of  the  liver  :  "  I  was  informed  by  an  officer  from  the  spot,  that 
nearly  all  the  men  belonging  to  a  regiment  of  horse  in  India,  died  within  a 
short  space  of  time  of  a  liver  complaint,  because  the  commanding  officer 
would  persevere  in  exercising  them  in  the  face  of  the  sun."  In  the  appen- 
dix to  the  same  work  are  found  remarks  by  M.  Fitzgerald,  Esq. :  "  A  gentle- 
man well  known  to  have  practiced  long  and  very  extensively  at  Madras."  He 
speaks,  "  from  much  experience  of  the  facts,"  and  states  that  great  mortality 
occurred  among  Europeans  by  reason  of  diseases  of  the  liver  from  heat,  espe- 
cially among  a  detachment  which  joined  Lord  Cornwallis' army  in  1790,which 

*  Transactions  of  the  American  Medical  Association,  vol.  vi.  p.  833. 
\  American  Journal  of  Medical  Science,  vol.  i.  1827. 


344:  Ajpjpendix. 

lost  most  of  its  men  from  this  cause.  He  adds,  that  although  intemperance 
may  be  a  cause,  yet  "  The  natives,  Dr.  Beddoes  may  rely,  sometimes  sufifer 
in  very  hot  seasons,  from  acute  inflammation  of  the  liver  without  the  assis- 
tance of  intemperance,  to  which  they  are  very  rarely  addicted."  A  very 
large  accumulation  of  facts  to  the  same  point  could  easily  be  made,  but 
these  are  deemed  sufficient. 


K. 

DIET     OP     INFANTS. 

Extract  from  an  article  ly  tlie  Author,  puilished  in  the  ^'■New  YorJc  Jour- 
nal of  Medical  Science" — July,  1844. 

The  period  of  infancy  presents  to  our  attention  circumstances  in  connec- 
tion with  diet,  which  have  no  parallel  at  any  other  time  of  life.  In  child- 
hood and  infancy  the  desire  for  food  is  frequent ;  capillary  action,  secretion, 
deposition,  and  interstitial  increase,  proceed  with  great  vigor, — all,  in  conse- 
quence of  this  period  being  the  period  of  growth ;  wherein  it  differs  very 
essentially  from  the  adult  state, — as,  in  the  latter,  the  action  of  vitality  is 
comprised  in  the  preserving  and  recuperative  processes ;  to  which  is  added, 
in  the  former,  that  of  the  development  of  the  body.  Growth  is  much 
greater  during  the  first  year  ;  and  the  constant  desire  for  food  during  that 
period  is  a  circumstance  of  common  observation.  In  young  infants,  the 
whole  time  is  occupied  with  receiving  nourishment  and  repose. 

With  this  peculiarity  of  early  infancy,  there  is  also  another  more  worthy 
of  note,  as  it  has  a  direct  practical  bearing  on  the  subject  before  us ;  and 
that  is  in  the  fact  that  the  food  of  all  animals,  in  their  earliest  period  of 
existence,  is  derived  from  animal  substances, — even  in  those  which  after- 
wards subsist  upon  vegetable  grains  ;  the  chick,  even  after  being  hatched, 
uses  a  part  of  the  egg  for  its  3.<)urishment.  Man,  after  infancy,  obtains 
his  nourishment  from  both  animal  and  vegetable  substances ;  and  the  great 
variety  of  articles  of  food  makes  a  curious  exhibition  of  his  omnivorous 
nature, — the  effect  of  custom,  climate,  religion,  etc.  The  carnivorous  pro- 
pensities of  the  people  at  the  extreme  North,  with  their  feasts  of  whale 
blubber,  and  the  Indian  Brahmin,  with  his  meal  of  rice ;  the  cannibal  of 
the  South  Pacific  Ocean,  and  luxurious  tables  prepared  by  the  most  scien- 
tific French  cuisinier  for  the  civilized  convivialist;  the  oak-bark  bread  of 
one  nation,  the  flesh-feast  furnished  by  dogs,  rats,  mice,  of  another ; — or 
the  snakes,  lizards,  caterpillars,  locusts,  worms,  and  other  reptiles,  of  the 


Appendix.  345 

African  negro ;  and  even  the  meal  of  clay  used  by  the  Otomacs,  as  men- 
tioned by  Humboldt,  certainly  present  a  wide  variety  in  the  articles  used 
for  sustenance,  without  considering  the  minutiae  of  our  daily  food,  to  prove 
that  man  is  omnivorous.  But  under  all  the  circumstances  of  climate, 
whether  in  the  frozen  region  of  the  North,  or  under  the  burning  sun  of  the 
tropics, — of  superstitious  customs,  or  savage  barbarity, — whatever  be  the  cir- 
cumstances influencing  the  character  and  quality  of  man's  diet,  there  is  for 
him  in  a  state  of  infancy,  but  one  kind  of  food — and  that  of  an  animal  nature 
Milk  is  his  sole  article  of  sustenance  until  the  time  when  a  change  in  his  sys- 
tem takes  place, — when  a  new  arrangement  of  his  organization  requires 
him  to  seek  his  food  among  more  varied  substances,  and  to  which  his  in- 
stinct invariably  directs  him.  Comparative  anatomy  affords  its  evidence 
to  the  necessity  of  adhering  to  this  one  kind  of  food.  The  form  of  the 
infant's  stomach  is  much  more  conical  than  that  of  the  adult,  and  resembles 
in  this  respect  the  stomach  of  carnivorous  animals ;  and  the  facility  with 
which  an  infant  vomits,  or  rather  regurgitates  its  food,  is  analogous  to  the 
ease  with  which  the  dog  or  cat  vomits  whenever  any  thing  is  swallowed,  even 
in  an  inconvenient  manner.  In  the  horse,  rabbit,  or  hare, — animals  alto- 
gether graminivorous, — the  stomach  differs  very  essentially  in  its  form,  resem- 
bling much  more  the  stomach  of  an  adult ;  vomiting  can  scarcely  be  excited, 
even  with  the  strongest  emetics.  The  nature  of  the  infant's  food  may  very 
rationally  be  inferred  from  this  analogy. 

if,  therefore,  nature  has  provided  but  one  kind  of  food  for  the  infant,  a 
sudden  change  to  substances  essentially  different  in  their  nature  must  be 
injurious  to  a  greater  or  less  extent ;  this  is  a  natural  and  direct  inference 
from  the  facts  already  stated.  In  adults,  where  every  species  of  food  is 
used,  an  entire  change,  and  a  restriction  to  one  course  of  diet,  are  always 
productive  of  important  effects  upon  the  general  system;  and  where  a 
scarcity  of  food  has  compelled  large  numbers  of  men  to  alter  their  food, 
and  suddenly  to  adopt  entirely  different  substances  from  what  they  were 
accustomed  to  eat, — as  was  the  case  in  some  parts  of  France,  in  the  year 
1817,  when  a  failure  of  the  crops  obliged  the  inhabitants  to  submit  to  great 
transition,  and  to  feed  upon  whatever  vegetables  could  be  found, — extensive 
disease  and  serious  permanent  effects  are  the  results. 

The  influence  of  an  entire  alteration  of  food,  from  its  powerful  effects 
upon  the  system,  causes  it  to  be  regarded  as  a  measure  of  great  value  in  the 
treatment  of  many  diseases;  and  the  change  to  vegetable  food  is  not  unfre- 
quently  an  important  remedial  measure.  In  the  adult,  such  a  change  is  but 
the  restriction  of  him  to  a  class  of  substances  that  is  natural  to  him,  and 
which  he  can  easily  assimilate ;  and  therefore  does  no  violence  to  his  phys- 
ical nature.  In  the  infant,  on  the  contrary,  the  adoption  of  a  vegetable 
diet  is  actually  contrary  to  the  arrangement  of  his  digestive  organs,  and  to 
the  provision  which  is  naturally  made  for  his  daily  sustenance ;  and  in  the 


346  Appendix. 

diseases  of  the  stomach  and  bowels,  must,  from  the  extra  demand  made 
upon  them  to  assimilate  substances  foreign  to  their  nature,  add  to  the  exist- 
ing derangement.  Acidity,  flatulency,  gripings,  diarrhoea,  and  other  symp- 
toms of  indigestion,  are  of  very  common  occurrence  in  young  infants ;  and 
indigestion  is  the  most  ordinary  affection  at  that  early  period,  showing  how 
easily  their  digestion  can  be  impaired.  A  very  obstinate  disease  will  some- 
times arise  in  infants  about  the  time  of  weaning,  and  particularly  if  the  change 
from  the  bland  food  furnished  by  the  mother  be  sudden ;  hence,  the  care  usu- 
ally taken  to  accustom  the  infant  to  a  different  species  of  food,  by  commencing 
feeding  it  some  time  before  this  period,  and  thus  gradually  accustoming  it 
to  the  necessary  alteration  of  diet.  If  this  precaution  is  necessary  to  pre- 
vent injury  where  nature  indicates  that  a  different  kind  of  food  is  required, 
how  much  more  care  is  needed  when  greater  injury  is  likely  to  arise  on  a 
sudden  change,  at  a  period  when  there  is  no  such  natural  indication,  and 
which  it  is  so  common  a  practice  to  disregard  upon  the  invasion  of  any 
affections  of  the  bowels.  Immediately  upon  the  appearance  of  these, 
arrow-root,  tapioca  or  sago  formed  into  jelly,  rice  or  barley-water,  is  given, 
from  the  supposed  bland  and  soothing  qualities  of  these  various  articles, 
which,  it  is  supposed,  render  them  peculiarly  applicable  to  the  inflamed 
mucous  membrane  of  the  parts  affected.  Such  is  undoubtedly  the  case  in  the 
majority  of  instances  in  childhood  and  at  adult  age,  but  in  infancy  I  very 
much  question  whether  this  course  is  followed  by  any  other  than  injurious 
effect.  I  have  watched  carefully  the  influence  of  these  substances  for  some 
years  past,  and  am  satisfied  that  the  additional  labor  the  digestive  organs 
have  to  perform,  in  their  attempts  to  assimilate  an  unnatural  food,  greatly 
aggravates  the  disorder  of  the  bowels ;  and  if  they  should  fail  in  digesting 
the  entire  quantity,  the  remainder  must  be  a  foreign  substance  to  the  bow- 
els, and  thereby  become  an  additional  source  of  irritation.  It  is  Mell  known 
that  vegetable  food  in  general  requires  for  its  digestion  more  time  and  more 
energetic  action  of  the  digestive  organs  than  animal  food ;  flatulency  and 
acidity  are  more  frequent  upon  its  use.  Under  ordinary  circumstances, 
feculent  nourishment  passes  much  more  quickly  through  the  intestines  than 
gelatinous,  albuminous,  or  fibrinous  food.  It  very  often  swells  and  under- 
goes some  degree  of  decomposition,  giving  rise  to  the  extrication  of  gas 
either  in  the  intestines  or  stomach ;  and  even  when  perfectly  digested, 
hunger  returns  very  quickly,  whenever  the  patient  is  kept  exclusively  upon 
it.  Some  kinds  of  food  are  much  more  difficult  to  digest  than  others,  and 
although  there  are  a  variety  of  circumstances  in  the  individual  which  influ- 
ence the  alteration  of  sustenance  taken  into  the  stomach,  yet  the  diges- 
tibility of  food  is  very  often  affected  by  circumstances  relating  to  the  food 
itself.  Thus,  fixed  oils  and  fat  are  slow  of  digestion,  as  is  known  to  all  • 
dyspeptics;  so  also  vegetable  substances  exhibit  this  indigestibility  in  a 
greater  or  less  degree,  when  in  a  crude  or  raw  state,  or  in  a  farinaceous  or 


Appendix.  347 

any  other  artificial  condition.  If  these  effects  are  produced  in  the  adult,  for 
the  reasons  already  mentioned,  it  must  be  much  more  the  case  in  the  infant ; 
and  many  an  instance  of  the  obstinate  perseverance  of  disease  of  these 
parts  may  be  referred  to  the  injudicious  system  of  feeding  during  its  prev- 
alence. 

It  is  a  rare  event  to  have  the  secrets  of  the  digestive  process  revealed, 
and  subjected  to  the  test  of  actual  experiment  during  life  or  on  a  postmor- 
tem examination.  The  former  has  been  exhibited  to  us  in  the  case  of  an 
adult,  by  Dr.  Beaumont ;  and  the  well-known  facts  there  elucidated  have 
been  considered  of  the  most  important  character.  Of  no  less  value  are  the 
facts  exhibited  by  postmortem  investigations  of  children,  made  at  Paris  a 
few  years  since,  by  M.  Natalis  Guillot,  for  the  purpose  of  ascertaining  the 
eonditionof  the  contents  of  the  bowels  of  such  as  died  under  the  use  of  the 
ordinary  diet  of  the  hospitals.  It  is  the  custom  at  these  and  similar  institu- 
tions, whenever  an  infant  is  sick  to  withdraw  it  from  the  breast,  and  to 
substitute  for  the  milk  some  farinaceous  substance  made  fluid  by  boiling  ; 
arrow-root,  gummed  rice  water,  or  a  thickened  preparation  of  rice,  known 
by  the  name  of  "  Creme  de  riz,"  and  other  preparations  of  a  similar  nature, 
forming  the  diet  of  the  sick  infant.  In  the  reported  cases  of  the  foundling 
hospital,  and  those  for  the  reception  of  sick  children,  prescriptions  of  this 
nature  form  a  very  important  part  of  the  treatment,  as  will  be  seen  by  re- 
ferring to  the  different  treatises  of  French  authors  on  diseases  of  children. 
The  mortality  in  the  French  hospitals  is  very  great ;  and  opportunities  are 
continually  afforded  for  examination,  in  such  numbers  as  to  establish  to  a 
certainty  almost  any  fact  which  requires  the  proof  of  anatomical  demonstra- 
tion. The  attention  of  M.  Guillot  being  directed  to  the  changes  which  the 
food  given  to  children  underwent,  and  to  the  excessive  mortality  among 
them,  he  instituted  a  series  of  investigations  in  a  number  of  cases  of  death, 
with  special  reference  to  the  state  of  the  contents  of  the  bowels.  He  was 
struck  with  the  uniform  similarity  ;  a  jelly-like  substance  being  present  in 
the  bowels,  and  in  some  instances  lining  both  the  small  and  great  intestines. 
This  was  subjected  to  the  test  of  the  tincture  of  iodine,  which  produced  an 
intensely  blue  color,  thus  proving  it  to  be  starch. 

Here  we  have  a  direct  proof  of  the  deficiency  of  the  digesting  power; 
the  articles  given  for  food  had  passed  through  the  length  of  the  intestines, 
and  had  undergone  very  little  change,  and  could  only  act  as  foreign  and 
irritating  substances.  The  almost  entire  suspension  of  the  digestive  process 
might  indeed  have  occurred  upon  the  use  of  any  description  of  food  ;  but 
when  it  is  considered  that  a  sudden  change  is  usually  attended  with  injury 
even  in  the  adult ;  that  vegetable  substances  are,  under  ordinary  circumstan- 
ces, more  difficult  to  digest  than  animal;  that  the  natural  food  of  the  infant 
is  entirely  dissimilar  in  its  nature  to  what  was  at  once  substituted  in  the  in- 
stances above  mentioned ;  we  might  very  reasonably  expect  to  find  a  sus- 


348  Appendix. 

pension  of  the  digestive  powers  a  very  serious  aggravation  of  disease,  and 
the  results  already  stated. 

From  all  the  facts  here  given,  it  appears  to  be  the  most  rational  course  to 
pursue,  to  preserve  as  much  uniformity  in  the  diet  as  the  nature  of  the  case 
and  attending  circumstances  will  admit.  If  in  health,  when  the  digestion  is 
unimpaired,  as  we  have  seen  food  of  an  animal  nature  is  the  proper  kind 
for  the  infant ;  in  disease  there  can  scarcely  be  any  alteration  to  food  of  an 
entirely  different  kind,  without  incurring  some  risk.  It  is  not  my  intention 
to  assert  that  no  alteration  whatever  is  to  be  adopted,  and  because  but  one 
kind  of  food  is  provided  for  the  infant,  that  it  would  be  hazardous  to  depart 
from  it  under  any  circumstances;  such  a  course  would  be  to  discard  all 
sound  theory,  to  abandon  all  attempts  at  controlling  disease,  and  if  fully 
carried  out  would  reach  even  to  the  administration  of  medicine  itself.  While 
we  avail  ourselves  of  the  plain  suggestions  of  science  and  the  accumulated 
experience  of  ages,  let  us  so  adapt  them  to  the  peculiar  condition  of  a  class  of 
individuals  as  not  to  do  a  positive  injury  by  their  injudicious  and  indiscrim- 
inate application.  The  aged,  the  robust,  the  toil-worn  laborer,  the  inhabi- 
tant of  the  city  or  of  the  country,  the  delicate  female  and  the  tender  infant, 
all  demand  some  modification  in  the  application  of  the  same  universally 
admitted  principles  of  medicine.  In  the  case  of  infants  we  can,  without 
removing  them  entirely  from  the  breast,  avail  ourselves  of  the  mild  and 
unirritative  effects  of  substances  of  the  same  nature  as  that  upon  which  the 
infant  feeds.  One  principal  reason  given  for  the  adoption  of  vegetable  muci- 
lage, such  as  infusion  of  flaxseed,  arrow-root,  etc.,  is  that  it  is  a  soft  and 
soothing  application  to  the  tender  and  inflamed  mucous  membrane.  Now 
if  the  same  object  can  be  attained  by  any  substance  that  possesses  the  same 
bland  qualities,  and  is  also  of  the  same  nature  as  the  infant's  food,  there 
will  be  no  necessity  for  resorting  to  substances  possessing  such  highly  un- 
digestible  qualities  as  those  of  a  vegetable  nature.  It  is  not  that  we  may 
alter  the  diet  from  the  compound  aliment,  milk ;  but  to  select  from  some 
simple  alimentary  substances,  which  it  is  deemed  advisable  to  employ  as 
medicinal  agents,  that  which,  from  its  essential  composition,  will  be  found 
more  nearly  allied  to  the  nourishment  which  nature  so  abundantly  supplies, 
and  thus  do  no  violence  to  the  physical  constitution. 


NOTE  TO  PAGE  300. 
We  have  to  add  to  the  postmortem  examination,  two  cases  recorded  by 
Dr.  W.  C.  Roberts,  in  the  N.  Y.  Med.  Gaz.,  Nov.,  1841,  one  by  Dr.  J.  A. 
Swett,  one  by  Dr.  Gross  reported  by  Dr.  W.  Parker  in  the  same  journal, 
in  the  paper  of  Dr.  Roberts,  and  one  furnished  to  the  author  in  MS.  by  Dr. 
J.  L.  Vandervoort.  In  all  these  five  cases  the  mucous  follicles  were  diseased  ; 
in  three,  the  liver  was  abnormal ;  in  one,  reported  healthy  ;  and  in  one,  that 
it  appeared  in  this  condition. 


M 


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